Professional Documents
Culture Documents
80
Friday,
No. 200
Part III
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SUMMARY:
DATES:
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CPOE Computerized Physician Order Entry
CQM Clinical Quality Measure
CY Calendar Year
DEC Data Element Catalog
eCQM Electronic Clinical Quality Measure
EHR Electronic Health Record
ELR Electronic Reportable Lab
EP Eligible Professional
ePHI Electronic Protected Health
Information
eRx Electronic Prescribing
FACA Federal Advisory Committee Act
FAQ Frequently asked question
FCC Federal Communications Commission
FFP Federal Financial Participation
FFS Fee-for-Service
FQHC Federally Qualified Health Center
FY Fiscal Year
HEDIS Healthcare Effectiveness Data and
Information Set
HHS Department of Health and Human
Services
HIE Health Information Exchange
HIT Health Information Technology
HIPAA Health Insurance Portability and
Accountability Act of 1996
HITECH Health Information Technology for
Economic and Clinical Health Act
HMO Health Maintenance Organization
ICR Information Collection Requirement
IFC Interim Final Rule with Comment
Period
IPPS Inpatient Prospective Payment System
IQR Inpatient Quality Reporting
IT Information Technology
MA Medicare Advantage
MACRA Medicare Access and CHIP
Reauthorization Act of 2015
MIPS Merit-Based Incentive Payment
System
MITA Medicaid Information Technology
Architecture
NPI National Provider Identifier
NPPES National Plan and Provider
Enumeration System
NwHIN Nationwide Health Information
Network
NQF National Quality Forum
ONC Office of the National Coordinator for
Health Information Technology
OTC Over the counter
PFS Physician Fee Schedule
PHA Public Health Agency
PHSA Public Health Service Act
POS Place of Service
PQRS Physician Quality Reporting System
PHI Protected Health Information
QA Quality Assurance
QRDA Quality Reporting Data Architecture
SMHP State Medicaid Health Information
Technology Plan
SRA Security Risk Assessment
ToC Transitions of Care
VDT View, Download, and Transmit
asabaliauskas on DSK5VPTVN1PROD with RULES
Table of Contents
I. Executive Summary and Background
A. Executive Summary
1. Purpose of Regulatory Action
a. Need for Regulatory Action
b. Legal Authority for the Regulatory
Action
2. Summary of Major Provisions
a. Considerations in Defining Meaningful
Use
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1. Overall Effects
a. EHR Technology Development and
Certification CostsStage 3
b. Regulatory Flexibility Analysis and
Small Entities
(1) Small Entities
(2) Conclusion
c. Small Rural HospitalsModifications
d. Unfunded Mandates Reform Act
e. Federalism
2. Effects on EPs, Eligible Hospitals, and
CAHs
a. Background and Assumptions
(1) EHR Incentive Programs in 2015
Through 2017
(2) Stage 3
b. Industry Costs and Adoption Rates
(1) Modifications
(a.) Medicare Eligible Professionals (EPs)
(b.) Medicare Eligible Hospitals and CAHs
(c.) Medicaid Only EPs
(d.) Medicaid Only Hospitals
(2) Stage 3
c. Costs of EHR Adoption for EPs
d. Costs of EHR Adoption for Eligible
Hospitals
3. Medicare and Medicaid Incentive
Program Costs for Stage 3
a. Medicare Program Costs for Stage 3
(1) Medicare Eligible Professionals (EPs)
(2). Medicare Eligible Hospitals and CAHs
b. Medicaid Incentive Program Costs for
Stage 3
(1). Medicaid EPs
(2). Medicaid Hospitals
4. Benefits for all EPs and all Eligible
Hospitals
5. Benefits to Society
6. Summary
D. Alternatives Considered for Stage 3
E. Accounting Statement and Table
(1) EHR Incentive Programs in 2015
Through 2017
(2) Stage 3
VI. Response to Comments
Regulations Text
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The Stage 3 proposed rule (80 FR
16733 through 16735) described the
final stage of the program, which would
incorporate portions of the prior stages
into Stage 3 requirements, while altering
other requirements in response to CMSs
progress toward policy goals, the
widespread adoption of technology and
clinical standards among providers, and
high performance on certain objectives
among providers. These proposed
changes included simplifying and
reducing the number of measures, and
focusing the Medicare and Medicaid
EHR Incentive Programs on the
advanced use of EHR technology. In
addition, the proposals set a path for
providers to move toward aligned
reporting on a single set of
requirements, with the goal of moving
all participants in the Medicare and
Medicaid EHR Incentive Programs to a
single set of requirements in 2018. The
incorporation of the requirements into
one stage for all providers is intended to
respond to stakeholder concerns by
creating simplicity in the program by
focusing on the success of certain
measures that are part of the meaningful
use program to date, and setting a longterm, sustainable foundation based on
key advanced use objectives for the
Medicare and Medicaid EHR Incentive
Programs.
In the EHR Incentive Programs for
2015 through 2017 proposed rule (80 FR
20346 through 20399), we proposed to
make similar modifications to Stage 1
and Stage 2 of the Medicare and
Medicaid EHR Incentive Programs in
order to reduce reporting burden, to
eliminate redundant and duplicative
reporting, and to better align the
objectives and measures of meaningful
use with the proposed Stage 3
requirements, which would be optional
in 2017 and required beginning in 2018.
In this final rule with comment
period, we are finalizing the
requirements for the EHR Incentive
Programs for 2015 through 2017 and for
2018 and subsequent years. We note
that our intent in finalizing the Stage 3
proposed rule along with the changes
for 2015 through 2017 while continuing
to solicit comments on certain
provisions is multifold; we are creating
consistency in the policies for the
current program in 2015 through 2017
and for 2018 and subsequent years; and
we have established a clear vision of
how current participation will assist in
meeting our long-term delivery system
reform goals. We believe this sustained
consistency in policy will support the
planning and development for MIPS
and the future use of EHR across a
multitude of healthcare providers.
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The December 7, 2012 IFC also revised
the Medicare and Medicaid EHR
Incentive Programs by
Adding an alternative measure for
the Stage 2 meaningful use objective for
hospitals to provide structured
electronic laboratory results to
ambulatory providers;
Correcting the regulation text for
the measures associated with the
objective for hospitals to provide
patients the ability to view online,
download, and transmit information
about a hospital admission; and
Making the case number threshold
exemption for CQM reporting applicable
for eligible hospitals and CAHs
beginning with FY 2013.
The December 7, 2012 IFC also
provided notice of our intention to issue
technical corrections to the electronic
specifications for CQMs released on
October 25, 2012.
In the September 4, 2014 Federal
Register (79 FR 52910 through 52933),
CMS and ONC published a final rule
titled Medicare and Medicaid
Programs; Modifications to the Medicare
and Medicaid Electronic Health Record
(EHR) Incentive Program for 2014 and
Other Changes to the EHR Incentive
Program; and Health Information
Technology: Revisions to the Certified
EHR Technology Definition and EHR
Certification Changes Related to
Standards; Final Rule (2014 CEHRT
Flexibility final rule). Due to issues
related to availability delays for EHR
technology certified to the 2014 Edition,
the 2014 CEHRT Flexibility final rule
included policies allowing EPs, eligible
hospitals, and CAHs that could not fully
implement EHR technology certified to
the 2014 Edition for an EHR reporting
period in 2014 to continue to use one
of the following options for reporting
periods in CY 2014 and FY 2014,
respectively
EHR technology certified to the
2011 Edition; or
A combination of EHR technology
certified to the 2011 Edition and EHR
technology certified to the 2014 Edition
for the EHR reporting periods.
Although the 2014 CEHRT flexibility
final rule did not alter the attestation or
hardship exception application
deadlines for 2014, it did make changes
to the attestation process to support
these flexible options for CEHRT. This
2014 CEHRT Flexibility final rule also
discussed the provisions of the
December 7, 2012 IFC and finalized
policies relating to the provisions
contained in the December 7, 2012 IFC.
In the November 13, 2014 Federal
Register, we published an interim final
rule with comment period titled
Medicare Program; Revisions to
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In addition, we understand that the
increase in thresholds proposed in the
Stage 3 rule may increase the work
required to achieve an individual
measure. However, we noted that part of
our decision making process in the
overall reduction of the number of
objectives in the program was to reduce
the burden on providers for those
measures by allowing them to focus on
advanced use objectives that support
clinical effectiveness, patient safety,
patient engagement, and care
coordination. We believe providers
should prioritize their efforts to strive to
achieve high performance on these
important measures. In addition, as
noted in the proposed rule (80 FR
16740), the statute specifically requires
the Secretary to seek to improve the use
of EHRs and health care quality over
time by requiring more stringent
measures of meaningful use (see, for
example, section 1848(o)(2)(A)(iii) of the
Act). Therefore, for these reasons, we
intend to continue to use measure
thresholds that may increase over time
and to incorporate advanced use
functions of CEHRT into meaningful use
objectives and measures.
Comment: A commenter on the EHR
Incentive Programs in 2015 through
2017 proposed rule suggested that with
Stage 3 in place, the Physician Quality
Reporting System (PQRS) program and
the Hospital Inpatient Quality Reporting
(IQR) Program should be eliminated in
2018.
Response: We cannot eliminate the
PQRS and Hospital IQR Programs
because they are required by statute (see
sections 1848(a)(8) and
1886(b)(3)(B)(viii) of the Act,
respectively). Furthermore, although
PQRS payment adjustments sunset after
2018 in accordance with section
101(b)(2)(A) of MACRA, certain
provisions and processes under PQRS
will continue to apply for purposes of
MIPS. MIPS is also required by statute
(see section 1848(q) of the Act, as added
by section 101(c) of MACRA). One of
the focal points for Stage 3, however, is
alignment with other quality programs
such as the Hospital IQR Program and
PQRS, not replacement of them.
Comment: A few commenters relayed
concerns regarding financial issues
related to costs associated with Stage 3
implementation, upgrading, installing,
testing, and maintenance of EHRs that
are outside of normal operating
practices. A commenter stated
maintenance of EHRs requires many
expenses that surpass what is
considered reasonable.
Response: We understand cost is a
factor for health care providers. Our goal
with Stage 3 is to simplify reporting
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participating in Stage 3 in 2017 and of
using technology certified to either the
2014 or 2015 Edition in 2017 and
believed this would provide relief to the
industry. Some commented they would
support this flexibility in all future
years where changes to CEHRT will be
required and noted transitioning to
technology certified to a new Edition
can be complex and can require more
resources and time than anticipated.
Other commenters suggested that
providing an optional year to transition
to technology certified to a new Edition
allows the time necessary to help ensure
a safe transition for patients and a
smoother transition for providers. Other
commenters were also appreciative of
CMS response to their concerns as
reflected in the Stage 3 proposed rule.
Some commenters on the EHR
Incentive Program in 2015 through 2017
proposed rule indicated that in the case
of unanticipated challenges or delays
with the adoption and implementation
of the technology certified to the 2015
Edition, CMS should preemptively
detail alternative scenarios to avoid
future rule changes.
However, other commenters stated
that 2017 is not a realistic start date for
Stage 3 due to the expected timing of
the final rule; necessary upgrades to
technology; transitional processes after
deployment such as training, workflow,
and validation of reporting; and full
year reporting requirements. A
commenter suggested there would be
only 1215 months from the publication
date of the final rule (assuming
publication in late 2015) until
technology certified to the2015 Edition
would need to be available from
vendors and developers and
implemented by organizations with
necessary staff training completed for
new workflows. Some commenters
indicated EHR vendors and developers
need on average 18 months to develop,
test, market, and implement new
functionality, while providers need lead
time to re-work their processes and
systems to new or revised requirements.
Other commenters indicated concern
about the timeline of transitioning to
Stage 3 in 2017 and 2018, stating that 18
months is the minimum length of time
needed between the final rules and the
start of any stage of the EHR Incentive
Program. Furthermore, as the change
requires a technology upgrade, and
given the likely timing for the
publication of the final rules, the
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TABLE 1STAGE OF MEANINGFUL USE CRITERIA BY FIRST YEAR
Stage of meaningful use
2015
2016
2017
2018
2011 ..................................
Stage 3 .......
Stage 3.
2012 ..................................
Stage 3 .......
Stage 3.
2013 ..................................
Stage 3 .......
Stage 3.
2014 ..................................
Stage 3 .......
Stage 3.
2015 ..................................
Stage 3 .......
Stage 3.
2016 ..................................
NA ....................................
Stage 3 .......
Stage 3.
2017 ..................................
NA ....................................
NA ....................................
Stage 3 .......
Stage 3.
2018 ..................................
2019 and future years .......
NA ....................................
NA ....................................
NA ....................................
NA ....................................
Stage 3 .......
NA ...............
Stage 3.
Stage 3.
2019 and
future years
* Indicates a new section that was proposed in the Stage 3 proposed rule. We indicated that all proposed changes in part 495 would be reconciled through this final rule with comment period.
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believed this would simplify the
reporting, monitoring, and attestation
for hospitals. Other commenters stated
aligning the reporting period would ease
provider reporting burden for larger
organizations that will not have to track
their providers through different stages.
Another commenter stated that this not
only allows those health IT vendors and
developers who service both outpatient
and inpatient clients to be better aligned
in their deployment and support, but
also permits them to better harmonize
technology implementation and
program reporting. Other commenters
stated that calendar year reporting,
combined with the new Active
Engagement options for public health
and clinical data registry reporting (see
section II.B.2.a.x of this final rule with
comment period), will permit them to
onboard, test, and deploy participants in
a timely manner based upon the ability
to meet their own internal resource
constraints, while ensuring all
participants can meet their meaningful
use objectives.
Response: We thank the commenters
for support of this proposal. As we
stated in the EHR Incentive Program in
2015 through 2017 proposed rule (80 FR
20353), the movement of all providers to
calendar year reporting supports
program alignment and simplifies
reporting requirements among provider
types.
Comment: A commenter stated the
move to reporting on the calendar year
would eliminate the 3-month gap that
currently exists between the end of the
hospital EHR reporting period and the
end of the EPEHR reporting period. This
could cause issues, especially among
organizations that share resources to
support build, testing, and report
validation for eligible hospitals, CAHs,
and EPs. Other commenters stated
aligning all providers to a calendar year
would diminish their time to
troubleshoot unexpected issues with
final reports and validate the accuracy
of data or lead to an increased risk in
data entry errors in order to meet the
February deadline for attestation for
both EPs, eligible hospitals, and CAHs.
Response: We understand the
concerns stated by stakeholders over the
changes proposed for the EHR reporting
periods. Because this final rule with
comment period maintains the existing
definitions for the objectives and
measures, including the numerator and
denominator calculations and measure
thresholds for 2015, we believe vendors,
developers, and providers will have
minimal issues in the upgrades and
testing for 2015. Likewise, the
requirements for 2015 through 2017 use
the existing measure specifications and
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Response: We note that this
perception is of concern and is not
reflective of our policy goals for the
program. As we stated in the EHR
Incentive Programs in 2015 through
2017 proposed rule (80 FR 20348), the
90-day EHR reporting period is intended
only to accommodate the changes to the
EHR Incentive Programs in 2015
through 2017, which are in turn
intended to drive toward the long-term
goals outlined in the Stage 3 proposed
rule.
Comment: A commenter requested
CMS acknowledge the challenges
associated with reporting on a full
calendar year for EPs newly employed
by a health system during the course of
a program year, switching EHRs, system
downtime, cyber-attacks, and office
relocation.
A few commenters strongly
recommended in the EHR Incentive
Program in 2015 through 2017 proposed
rule that CMS retain the 90-day
attestation option for providers who
change employers during the year.
Furthermore, the commenters further
stated they do not believe an
organization can sufficiently rely upon
the actions of a previous employer to
complete the necessary validation,
analysis, and implementation of an EHR
that would satisfy CMS audit
requirements. If a previous employers
data is found to be faulty, the current
organization is put at risk for the data
reported.
Response: We understand the
commenters concerns and note that EPs
may consider applying for a hardship
exception from the reduction to
Medicare PFS payments based on
extreme and uncontrollable
circumstances. Specifically, in the case
of issues related to CEHRT, situations
involving technology upgrades,
switching products during the year, or
the decertification of a product may be
reason for a provider to apply for a
hardship.
EPs who are switching employment or
practicing in multiple locations during
an EHR reporting period may apply for
a hardship exception that would be
reviewed on a case-by-case basis.
However, we disagree that CMS should
take into account the business practices
of individual EPs in establishing the
requirements for the entirety of the
program. It is incumbent on the
individual EP to establish their own
contractual or business arrangements for
the purposes of attesting for the
Medicare and Medicaid EHR Incentive
Programs.
Comment: A commenter suggested the
EHR reporting period should be at least
90 days or 3 calendar months. The
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we refer readers to section II.C of this
final rule with comment period.)
Comment: A number of commenters
requested a 90-day reporting period for
providers in the first year of Stage 3
especially for any providers seeking to
demonstrate the Stage 3 objectives and
measures in the optional year in 2017.
Some of these commenters indicated
that they agree with the need for full
year reporting, but believe that it is
appropriate to allow a 90-day EHR
reporting period when providers move
to a new stage in order to mitigate issues
with workflows, ensure the effective
implementation of new technologies,
and integrate new processes into
clinical operations.
Response: We disagree that a 90-day
EHR reporting period is appropriate for
all providers moving to Stage 3, as we
believe the lead time required for
participation in 2018 is sufficient. In
addition, the optional year in 2017
allows providers to work toward the
Stage 3 measures and test workflows
prior to their required implementation
in 2018. However, we agree that the
allowance of a 90-day EHR reporting
period may be appropriate for providers
attesting to the objectives and measures
of Stage 3 in 2017. A 90-day EHR
reporting period in this case would
recognize the shorter time period from
development of the technology to
implementation for use in 2017 and a
shorter time period for the necessary
testing and implementation of
workflows and new technologies. A 90day EHR reporting period in 2017
would allow for further flexibility in the
installation and implementation of the
overall upgrade to technology certified
to the 2015 Edition by spreading out the
demand over a greater period of time. In
addition, a 90-day EHR reporting period
in 2017 for Stage 3 providers would
provide a benefit by easing the
transition for those providers who
choose to move to Stage 3 early and will
potentially make that choice more
accessible for a greater number of
providers. Therefore, we agree that
allowing a 90-day EHR reporting period
for Stage 3 providers in 2017 would
support the transition to a new
technology, the adoption of technology
and clinical workflows, and the overall
progress toward program goals.
After consideration of the public
comments received, we are finalizing
our proposal to require a full CY EHR
reporting period for all providers (with
a limited exception for new meaningful
EHR users under Medicaid) beginning
in CY 2017, with a modification for
providers attesting to Stage 3 of
meaningful use in 2017. For EPs,
eligible hospitals, and CAHs that choose
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Comment: Another commenter is
concerned that by suddenly eliminating
measures, CMS may be creating
uncertainty and inadvertently sending
the message that sustained performance
is no longer necessary. The commenter
believes it is important that EPs be given
proper notice of the agencys plans for
eliminating measures.
Some commenters stated removing
the measures may lead to EHR vendors
and developers not providing metrics on
the measures in reports that are used for
benchmarking and internal quality
improvement work. These commenters
recommended that providers should
continue to be required to report on all
topped out measures without a
threshold, where the measure would be
to attest that the provider is recording
the information.
Response: We notified the public of
our intent to remove measures from the
program through notice of proposed
rulemaking and requested public
comment on these changes in both the
Stage 3 proposed rule and the EHR
Incentive Programs in 2015 through
2017 proposed rule. In addition, as
noted in the Stage 3 proposed rule (80
FR 16741), evaluation of measures and
performance is common practice for
CMS programs to ensure ongoing
program effectiveness.
We disagree that threshold measures
should be replaced with check box
measures for each of the topped out
measures as this would provide no
value for measurement and is counter to
the effort to reduce the reporting burden
on providers. Providers who wish to
independently measure the capture of a
particular data element should work
with their EHR developer and vendor to
ensure they are receiving the most
appropriate analytics for their practice
and patient populationjust as they
would with any data element they
wished to track that was not already
required by the Medicare and Medicaid
EHR Incentive Programs.
Comment: A few commenters stated
the impact of reducing the reporting
burden for meaningful use is minimal
and that the burden of meeting the
requirements of the EHR Incentive
Programs lies in bridging clinical
workflow and best practices, patient
safety, technology, and program
understanding.
Response: While we agree that the
objectives and measures required in the
program are directly correlated with
clinical workflows, technology, program
understanding, and patient safety, we
are responding to concerns stated by a
wide range and significant number of
stakeholders, including the burden of
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part of the CCDA in an electronic
exchange and the information provided
to a patient through the view,
download, and transmit functions of
CEHRT. For further information, we
refer readers to the ONC 2015 Edition
Certification Criteria final rule
published elsewhere in this Federal
Register.
After consideration of the public
comments received, we are finalizing
our proposed approach for analyzing the
objectives and measures to identify and
maintain and promote the advanced use
of health IT for Stage 3 of meaningful
use.
(b) Considerations in Defining the
Objectives and Measures of Meaningful
Use for 2015 Through 2017
In the EHR Incentive Programs in
2015 through 2017 proposed rule (80 FR
62785
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their ability to successfully fulfill the
requirements of the EHR Incentive
Programs.
(ii) Structural Requirements of
Meaningful Use in 2015 Through 2017
In the EHR Incentive Programs in
2015 through 2017 proposed rule, we
proposed to eliminate the distinction
between core and menu objectives and
purported that all retained objectives
would be required for the program. We
note that for Stage 1 providers, this
means three current menu objectives
would now be required; and for Stage 2
eligible hospitals and CAHs, one current
menu objective would now be a
required objective (80 FR 20356). These
objectives are as follows:
Stage 1 Menu: Perform Medication
Reconciliation
Stage 1 Menu: Patient Specific
Educational Resources
Stage 1 Menu: Public Health
Reporting Objectives (multiple
options)
Stage 2 Menu: Eligible Hospitals and
CAHs Only: Electronic Prescribing
Furthermore, we stated that the
objectives and measures retained in
each case for all providers would be the
Stage 2 objectives and measures and
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EH/CAH .................
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9 core objectives.
1 public health objective (2 measure
options).
8 core objectives.
1 public health objective (3 measure
options).
Retained objectives
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9 core objectives.
1 public health objective (2 measure
options).
8 core objectives.
1 public health objective (3 measure
options).
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a significant risk to patient safety if the
technology is implemented incorrectly
in order to meet an expedited timeline.
Response: We understand the
commenters concerns that meeting the
Modified Stage 2 requirements may be
challenging for some providers for those
objectives and measures that would
require the implementation of
additional CEHRT modules they did not
previously possess because they were
not scheduled to be in Stage 2 or
because they did not intend to attest to
the menu objective. In general, the
timing to implement these new
technologies would not necessary be
prohibitive for a provider to
successfully participate in 2016;
however, as some commenters
mentioned there are patient safety risks
associated with the effective
implementation of the technology and
the supportive workflows which are of
concern for certain objectives. To
accommodate these concerns, we will
allow providers who would otherwise
be scheduled for Stage 1 in 2016 to
claim the alternate exclusions for the
Modified Stage 2 objectives and
measures that would require the
effective implementation of CEHRT
modules for an EHR reporting period in
2016 that the provider does not
currently possess. Specifically, we
believe this includes measures 2 and 3
(lab and radiology orders) of the
Computerized Provider Order Entry
Objective for EPs, eligible hospitals, and
CAHs, as well as the Electronic
Prescribing Objective for eligible
hospitals and CAHs. However, we do
not believe this extension should
include the Health Information
Exchange Objective for a number of
reasons. First, we have already proposed
additional flexibility for that objective
in 2015 through 2017 regarding the
CEHRT requirement for the
transmission of an electronic summary
of care document. Second, we believe
the threshold of 10 percent associated
with the Health Information Exchange
Objective and measure is achievable
within a calendar year. Finally, we
believe that the ability of all providers
to successfully exchange health
information electronically is enhanced
by greater participation among
providers as a whole. We also do not
believe that providers who otherwise
would be scheduled for Stage 1 in 2016
should be allowed to use for an EHR
reporting period in 2016 the alternate
specifications that we proposed for
2015, as these are only applicable for
measures that already have both a Stage
1 and Stage 2 equivalent and are
supported by measures using the same
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TABLE 4OBJECTIVES AND MEASURES FOR MEANINGFUL USE IN 2017 AND SUBSEQUENT YEARS
Program goal/objective
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Office visits.
All medication, laboratory, and
diagnostic imaging orders created
during the reporting period.
Transitions of care and referrals
including:
++ When the EP is the recipient of
the transition or referral, first
encounters with a new patient and
encounters with existing patients where
a summary of care record (of any type)
is provided to the receiving EP.
++ When the EP is the initiator of the
transition or referral, transitions and
referrals ordered by the EP.
For the purposes of distinguishing
settings of care in determining the
movement of a patient, we proposed
that a transition or referral may take
place when a patient is transitioned or
referred between providers with
different billing identities, such as a
different National Provider Identifier
(NPI) or hospital CMS Certification
Number (CCN). We also proposed that
in the cases where a provider has a
patient who seeks out and receives care
from another provider without a prior
referral, the first provider may include
that transition as a referral if the patient
subsequently identifies the other
provider of care.
For eligible hospitals and CAHs, the
references used to define the scope of
the potential denominators for measures
include the following:
Unique patients admitted to the
eligible hospitals or CAHs inpatient or
emergency department during the EHR
reporting period.
All medication, laboratory, and
diagnostic imaging orders created
during the reporting period.
Transitions of care and referrals
including:
++ When the hospital is the recipient
of a transition or referral, all admissions
to the inpatient and emergency
departments.
++ When the hospital is the initiator
of the transition or referral, all
discharges from the inpatient
department, and after admissions to the
emergency department when follow-up
care is ordered by authorized providers
of the hospital.
We proposed that the explanation of
the terms unique patients,
transitions of care, and referrals
stated previously for EPs would also
apply for eligible hospitals and CAHs,
and we refer readers to the discussion
of those terms in the hospital context in
the Stage 2 final rule (77 FR 53983 and
53984). We proposed for Stage 3 to
maintain the policy that admissions
may be calculated using one of two
methods (the observation services
method and the all emergency
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hospitals and CAHs. We further specify
that in order to meet this objective and
measures, an EP, eligible hospital, or
CAH must use the capabilities and
standards of as defined for as defined
CEHRT at 495.4. We direct readers to
section II.B.3 of this final rule with
comment period for a discussion of the
definition of CEHRT and a table
referencing the capabilities and
standards that must be used for each
measure.
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explanation was provided in the
preamble of the proposed rule for Stage
3, but not in the 2015 through 2017
proposed rule.
Response: We did not propose
changes to our policy on protocol or
standing orders from Stage 2. We
reiterate from the Stage 2 final rule that
we agree that this category of orders
warrant different considerations than
orders that are due to a specific clinical
determination by the ordering provider
for a specific patient. Therefore, we
allow providers to exclude orders that
are predetermined for a given set of
patient characteristics or for a given
procedure from the calculation of CPOE
numerators and denominators. Note this
does not require providers to exclude
this category of orders from their
numerator and denominator (77 FR
53986).
Comment: A commenter requested
clarification defining what constitutes
an order (for example, whether an
order is equivalent to a single
transaction or if each order code in the
single transaction represents an
individual) order. The commenter also
inquired whether a laboratory panel/
profile test is counted as one order.
Response: Each order that is
associated with a specific code would
count as one order. Multiple tests
ordered at the same time count
individually if they fall under a
different order code. For example, a
laboratory panel, which consists of one
order code but multiple tests, would
only count as one order for the purposes
of CPOE. If those tests were ordered
individually with each having its own
order code, each test would count as an
order.
Comment: Several commenters
requested that for CPOE measure 2 lab
orders, we modify the exclusion criteria
to include circumstances where there
are no receiving centers for electronic
radiology orders or lab orders in case
there are no local or regional imaging
centers that are set up to receive or
transmit CPOE. Another commenter
believed there should be an additional
exclusion for measure 2 to address
instances in which the lab does not
want to connect electronically due to
the low number of lab orders submitted
by the physician. One commenter stated
CPOE measures are not relevant or
valuable for physician office or
outpatient settings and should be
limited only to inpatient settings such
as hospitals.
Some commenters stated that the
CPOE objective should be considered
topped out.
Response: We respectfully disagree
with the commenters. CPOE is the entry
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reporting period beginning in 2016, all
EPs must meet the specifications and
threshold for the retained Stage 2
measure in order to successfully
demonstrate meaningful use.
Proposed Alternate EP Measure: More
than 40 percent of all permissible
prescriptions written by the EP are
transmitted electronically using CEHRT.
We proposed no alternate exclusions
for this EP objective.
Comment: We received a number of
comments in support of this objective
including commenters who stated that
clinicians support electronic prescribing
if it is efficient and does not interfere
with workflows. Of those who
supported the objective, most believe
that electronic prescribing has clear
patient and provider benefits,
specifically with helping to reduce
prescription errors. Some commenters
also supported the proposal to continue
to exclude over-the-counter medications
from the definition of prescription for
the purposes of the electronic
prescribing objective. Commenters
specifically stated support, noting that
the use of electronic prescribing will
reduce the number of prescription drug
related adverse events, deter the
creation of fraudulent prescriptions, and
decrease the opportunity for
prescription drug misuse and abuse.
Finally, a commenter noted that the
inclusion of the drug formulary query
will support CMS efforts to reduce the
financial burden to the patient.
Response: We thank the commenters
for their insight and support of this
objective.
Comment: One topic of concern
expressed by commenters was how
controlled substances would be
addressed in this final rule with
comment period given that there are
certain state restrictions on how
providers can prescribe controlled
substances. Commenters stated that in
the past, previous mandates stated that
prescriptions for controlled substances
were required have to be written, not
electronically prescribed. Many
commenters indicated they believe the
inclusion of controlled substances
should remain optional and depend on
whether or not the state allows the
electronic prescription submission of
these types of drugs. However, other
commenters noted that many states now
allow controlled substances to be
electronically prescribed either for all
prescriptions or for certain
circumstances and types of drugs. These
commenters noted that controlled
substances should be included where
feasible, as the inclusion would reduce
the paper-based prescription process
often used for such prescriptions, as
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currently challenges involved in
effectively completing a query of a drug
formulary universally which may cause
an additional burden on providers.
Commenters also noted that the ability
to include or exclude controlled
substances should be continued but
made more flexible to reflect the
changes regarding the allowance and
feasibility of electronic prescribing for
these medications. Some commenters
noted this would be especially
important for eligible hospitals and
CAHs serving patients in a wide
geographic region which may overlap
multiple jurisdictions. These
commenters noted that a change around
the language to make it more flexible
would allow them to include
prescriptions for controlled substance
based on an organizational policy that
addressed any potential discrepancies.
Other commenters requested
clarification on the approach for
internal pharmacies and drugs
dispensed on site.
Finally, other commenters provided
feedback on the request for comment
regarding refill prescriptions and
continued medications and whether the
measure language should be modified to
only mention new prescriptions or
new or changed prescriptions rather
than the proposed continuation of
including new, changed, and refilled
prescriptions. The vast majority of
commenters did not support including
refilled prescriptions noting that these
prescriptions should be included and
monitored by the original prescriber.
Commenters were divided on whether
to include or exclude changed
prescriptions. Some noting, again, that
changed prescriptions should be
monitored by the original prescriber
while others noted that the change
constitutes accountability for the
prescription by the eligible hospital.
Response: We agree these concerns
are applicable for both the EP and the
eligible hospital/CAH measures. The
guidance we provided above regarding
how providers may count the query of
a formulary for the EP measure is also
applicable for the eligible hospital/CAH
measure. For controlled substances,
based on public comment received we
are finalizing similar changes to the
denominator for the eligible hospital
objective as were adopted for the EP
objective to allow for the inclusion or
exclusion of these prescriptions at
provider discretion where allowable by
law. We further note that prescriptions
from internal pharmacies and drugs
dispensed on site may be excluded from
the denominator. Finally, we thank the
commenters for their insight and will
exclude refill prescriptions but maintain
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laboratory test results. The commenters
suggested that allowing individual
providers some flexibility to determine
what is important and relevant to send
to the next provider in care would allow
receiving providers to process and use
the information more effectively.
Response: First, we note that we did
not intend to cause this confusion. As
stated in the EHR Incentive Program in
2015 through 2017 proposed rule at (80
FR 20361) we proposed to maintain the
second measure of the Stage 2 Summary
of Care Objective with certain
modifications. For efficiency and to
reduce the overall length of the
proposed rule, we focused our
discussion on the proposed
modifications and referenced the full
description of the measure in the Stage
2 final rule at 77 FR 54013 through
54021. The only modifications that we
intended to make were those that we
expressly discussed, and unless we
indicated otherwise, our intention was
to maintain the existing Stage 2 policies
for the measure. This includes
maintaining the requirements for the
data elements included in the summary
of care document at 77 FR 54016 as
follows:
All summary of care documents used
to meet this objective must include the
following information if the provider
knows it:
Patient name.
Referring or transitioning providers
name and office contact information (EP
only).
Procedures.
Encounter diagnosis
Immunizations.
Laboratory test results.
Vital signs (height, weight, blood
pressure, BMI).
Smoking status.
Functional status, including
activities of daily living, cognitive and
disability status.
Demographic information
(preferred language, sex, race, ethnicity,
date of birth).
Care plan field, including goals and
instructions.
Care team including the primary
care provider of record and any
additional known care team members
beyond the referring or transitioning
provider and the receiving provider.
Discharge instructions (Hospital
Only)
Reason for referral (EP only)
In circumstances where there is no
information available to populate one or
more of the fields listed previously,
either because the EP, eligible hospital,
or CAH can be excluded from recording
such information (for example, vital
signs) or because there is no information
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While we encourage the use of querybased exchange for many use cases, we
note that to count in the numerator the
sending provider must reasonable
certainty of receipt of the summary of
care document. This means that a
push to an HIE which might be
queried by the recipient is insufficient.
Instead, r the referring provider must
confirmation that a query was made to
count the action toward the measure.
We further specify that the exchange
must comply with the privacy and
security protocols for ePHI under
HIPAA.
We thank the commenters for the
suggestion around the concept of an
information exchange address
repository. We agree that a potential
model which might allow for easier
access to health information exchange
contact information could be a positive
step toward supporting interoperability
and an improved care continuum. We
refer readers to section II.D.3 of this
final rule with comment period for
further discussion of the collection of
direct addresses or health information
exchange information for potential
inclusion in a nationwide healthcare
provider directory. After consideration
of public comments received, we are
finalizing this objective, measure,
exclusion, and alternate exclusion as
proposed for EPs, eligible hospitals, and
CAHs as follows:
Objective 5: Health Information
Exchange
Objective: The EP, eligible hospital or
CAH who transitions their patient to
another setting of care or provider of
care or refers their patient to another
provider of care provides a summary
care record for each transition of care or
referral.
Measure: The EP, eligible hospital or
CAH that transitions or refers their
patient to another setting of care or
provider of care must(1) Use CEHRT
to create a summary of care record; and
(2) electronically transmit such
summary to a receiving provider for
more than 10 percent of transitions of
care and referrals.
Denominator: Number of transitions
of care and referrals during the EHR
reporting period for which the EP or
eligible hospitals or CAHs inpatient or
emergency department (POS 21 or 23)
was the transferring or referring
provider.
Numerator: The number of transitions
of care and referrals in the denominator
where a summary of care record was
created using CEHRT and exchanged
electronically.
Threshold: The percentage must be
more than 10 percent in order for an EP,
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of standards and testing, we believe the
requirement of these tools for all
providers in the Medicare and Medicaid
EHR Incentive Programs is premature
based on the current availability of such
interoperable resources in the EHR
marketplace.
Comment: Some commenters
requested clarification if the transitive
effect described in FAQ 7735 and FAQ
9686 applies for the patient-specific
education objective as well. These
commenters note that if patient-specific
education is provided via a patient
portal, it is very difficult to measure as
attributable to a specific provider within
a group practice or even across settings
if providers are sharing an EHR.
Response: FAQ7735 and FAQ 9686
refer to the Patient Electronic Access
Objective measures 2 and the Secure
Electronic Messaging Objective
respectively,9 and allow for a single
action by a patient to count in the
numerator for multiple providers under
certain circumstances if each of the
providers has the patient in their
denominator for that EHR reporting
period. In each case, this policy is
intended to facilitate calculation in
circumstances where accurate
calculation and attribution of the action
to a single provider may be impossible.
This is not inherently the case with the
patient-specific education objective
which is why this objective is not
included in either FAQ. The Stage 2
Patient-specific Education Objective (80
FR 20362) does not limit the measure to
education provided via a patient portal
and therefore a universal policy
allowing the transitive effect would
not be appropriate. For example, if a
provider gives a patient a paper-based
educational resource during their office
visit, that instance is only attributable to
that provider and should not be counted
in the numerator for other providers
within the group practice. However, if
the resource is provided electronically
and such attribution is impossible, it
may be counted in the numerator for
any provider within the group sharing
the CEHRT who has contributed
information to the patients record, if
that provider also has the patient in
their denominator for the EHR reporting
period. We recognize that this may
result in a process of manual calculation
if both electronic and paper-based
resources are used. While we are
seeking to avoid manual calculation and
paper-based actions, we must also
balance avoiding unintended negative
9 CMS.gov Frequently Asked Questions: EHR
Incentive Programs FAQ 7735: https://
questions.cms.gov/faq.php?id=5005&faqId=7735
and FAQ 9686: https://questions.cms.gov/
faq.php?id=5005&faqId=9686.
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20363) we proposed to maintain the
definition for this objective from the
Stage 2 final rule when the EP is the
recipient of the transition or referral,
first encounters with a new patient and
encounters with existing patients where
a summary of care record (of any type)
is provided to the receiving EP (77 FR
53984). We note that the reconciliation
occurs with the transition or referral,
not with the receipt of the summary of
care document. Therefore, if a provider
receives duplicate summaries for a
single referral such an action must only
be counted once. In addition, the action
of reviewing the medication list to
determine if there are changes or
confirm that there are no changes would
meet the requirements of the objective
to count as an action in the numerator.
Comment: Commenters requested that
CMS define what a new patient is for
the purposes of the definition of a
transition or referral. For example, one
commenter noted that in their billing
practices they define a patient as new
if they have not been seen in 2 years.
The commenter noted that using this
definition in the denominator would
include a greater number of relevant
patient encounters than our current
definition which uses patients who
were never before seen by the provider.
The commenter suggested this
definition would ensure that these
patients records were also updated
which would be a significant benefit.
Response: In the EHR Incentive
Programs in 2015 through 2017
proposed rule (80 FR 20363) as in the
Stage 2 final rule (77 FR 54013), we
consider a patient to be a new patient
if he or she has never before been seen
by the provider. We agree that the
commenters definition of new
patient may capture a wider range of
patients for whom medication
reconciliation would be relevant and
beneficial. While we will not change the
denominator for this existing objective,
a provider may use an expanded
definition which includes a greater
number of patients for whom the action
may be relevant within their practice.
We intend that our description of a new
patient is a baseline that a provider
must meet; however, if that requirement
is met the provider may include further
actions or addition encounters relevant
to their practice and patient population,
so long as the approach is applied
universally across all such encounters,
all settings and for the duration of the
EHR reporting period.
Comment: A commenter requested
clarification of whether the denominator
of medication reconciliation includes
first encounters with all new patients
(in other words, encounters in which
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Stage 3 level. They recommended a
phased approach that recognizes the
challenges that some providers are
encountering as they try to get their
patient population more engaged with
viewing, downloading or transmitting
their information to a third party. They
believe that a higher measure threshold
will be easier to achieve as the
technology becomes even more userfriendly and patients begin to see the
value in becoming more involved in
their own care and taking these actions.
Overall, they believe a phased-in
approach for the patient electronic
access objective would be an
appropriate and balanced step forward.
Response: We agree that providers
have a role in promoting behavioral
change among patients in regard to
engaging with their health information
and increasing health literacy and that
provider influence may be a factor.
However, as noted in the EHR Incentive
Programs in 2015 through 2017
proposed rule (80 FR 20357), statistical
analysis of measure performance shows
a wide variance, and further analysis in
comparison to the first measure does not
show a correlation between provider
action and patient response.11 Through
our analysis we found that neither high
nor low performance on the first
measure nor an overall increase or
decrease in the number of patients who
have access to their data, had a strong
or moderate correlation to performance
on patient action either for high
performers or low performers. This
suggests that other external factors
currently impact performance on the
objective. This may include a lag in the
adoption of technologies by patients,
patient self-selection, or other unknown
factors related to the IT environment
and the patients themselves. We believe
that continued efforts to raise awareness
and provide access through a wider
range of electronic means (such as the
inclusion of APIs in the Stage 3
measure) will help to expand the
adoption of this technology over time,
and we maintain that providers should
be supported in that effort rather than
having additional burden added for
factors outside their control.
We wish to reiterate that we
understand the concerns voiced by
providers regarding patient populations
that are unable to engage in their health
care information electronically due to
various factors, which include income,
age, technological capabilities, or
comprehension. We agree with the
phased approach recommended by the
11 EHR Incentive Programs Performance Data:
Program Data and Reports: www.cms.gov/EHR
Incentive Programs.
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information. We agree with the intent
behind the policy and support the
policy goal of promoting enhanced
patient and provider engagement, and
leveraging HIT solutions to enhance
patient and provider communications.
We direct readers to the proposed
measure we included for the Stage 3
Objective for Coordination of Care
through Patient Engagement in section
II.B.2.b.vi of this final rule with
comment period. We would like to
highlight some key differences between
the Stage 3 proposed objective and the
current objective, which are the result of
lessons learned through feedback over
the past few years from providers about
their efforts to implement the
requirements of the EHR Incentive
Program. We believe this will help to
illustrate why we proposed to reduce
the threshold for this Secure Messaging
objective and how we are seeking to
maintain the policy of moving patient
engagement forward.
As noted in the Stage 3 proposed rule
(80 FR 16756) and for the Stage 3
objective in section II.B.2.b.vi of this
final rule with comment period, we
included proposals for bi-directional
communication and communications
among and between the patient and
multiple providers in a care team. We
also expanded the potential role of
patient-authorized representatives, and
we sought to adopt a wider range of
communications methods that could
support and promote patient-centered
care coordination. We proposed this
objective because we believe that
leveraging health IT to support care
team communications in which a
patient is actively engaged can lead to
better care coordination and better
outcomes for the patient. However, the
current Stage 2 secure messaging
objective as finalized in the 2012 Stage
2 final rule (77 FR 54031) does not
include this flexibility of form, method
and participation. It includes only
patient-initiated communication rather
than provider driven engagement, and it
does not promote a wide range of use
cases. Comments received indicate that
this is a significant shortfall in the
language of the current measure
supporting the identified health care
delivery system reform goal. In addition,
commenters note that these factors and
other environmental or patient related
factors create a significant burden on
providers and negatively impact a
providers ability to meet the measure.
This means that providers are investing
a large amount of resources to achieve
a measure that is flawed, does not
adequately meet the intended health
goal, and provides only a limited value.
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patient-authorized representative), or in
response to a secure message sent by the
patient (or the patient-authorized
representative) during the EHR
reporting period.
Denominator: Number of unique
patients seen by the EP during the EHR
reporting period.
Numerator: The number of patients
in the denominator for whom a secure
electronic message is sent to the patient
(or patient-authorized representative), or
in response to a secure message sent by
the patient (or patient-authorized
representative).
Threshold: The resulting percentage
must be more than 5 percent in order for
an EP, eligible hospital, or CAH to meet
this measure.
Exclusion: Any EP who has no office
visits during the EHR reporting period,
or any EP who conducts 50 percent or
more of his or her patient encounters in
a county that does not have 50 percent
or more of its housing units with 4Mbps
broadband availability according to the
latest information available from the
FCC on the first day of the EHR
reporting period.
Alternate Exclusion:
Alternate Exclusion: An EP may claim
an exclusion for the measure if for an
EHR reporting period in 2015 they were
scheduled to demonstrate Stage 1,
which does not have an equivalent
measure.
We are adopting Objective 9: Secure
Electronic Messaging at 495.22(e)(9)(i)
for EPs. We further specify that in order
to meet this objective and measures, an
EP must use the capabilities and
standards of as defined for as defined
CEHRT at 495.4. We direct readers to
section II.B.3 of this final rule with
comment period for a discussion of the
definition of CEHRT and a table
referencing the capabilities and
standards that must be used for each
measure.
Objective 10: Public Health and Clinical
Data Registry Reporting
In the EHR Incentive Programs in
2015 through 2017 proposed rule 80 FR
20366,we proposed to adopt a modified
version of the consolidated Public
Health and Clinical Data Registry
Reporting objective proposed in the
Stage 3 proposed rule for all providers
to demonstrate meaningful use for an
EHR reporting period in 2015 through
2017.
Proposed Objective: The EP, eligible
hospital or CAH is in active engagement
with a Public Health Agency (PHA) or
clinical data registry (CDR) to submit
electronic public health data in a
meaningful way using CEHRT, except
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meeting the active engagement
requirement of this objective.
Comment: Many commenters
expressed concern regarding whether
provider and developers would have
adequate time to implement a new
active engagement requirement in place
of the ongoing submission requirement
in time to successfully attest for an EHR
reporting period in 2015.
Response: We note that while the
active engagement options included in
the EHR Incentive Program for 2015 to
2017 replace the ongoing submission
requirement included in the Stage 2
final rule, they should not be considered
mutually exclusive. We note that for
providers who have already planned for
and/or acted toward meeting any of the
Stage 1 or Stage 2 public health
reporting objectives, those actions
would count toward meeting the active
engagement options.
For clarification on the rationale
behind this change, we note that over
the past few years, we have received
feedback on the Stage 1 and Stage 2
public health reporting objectives
through letters, public forums, and
individual inquiries from both
providers/provider representatives and
from public health agencies. The
common trend in these communications
is that the difference between the Stage
1 and Stage 2 requirements and the
ongoing submission structure for the
Stage 2 objectives created confusion
around both the actions required and
the timing of those actions for providers.
The active engagement requirement
clarifies what is expected of a provider
who seeks to meet the measures within
this objective and more accurately
describes the actions necessary to meet
each option within the structure. This
does not mean that actions a provider
has already taken in an attempt to meet
the ongoing submission requirement
would not be acceptable under the new
objective. Any action which would be
acceptable under the Stage 1 and Stage
2 public health reporting objectives
would fit within the definition of the
active engagement options. In
addition, because of the similarity
between the substantive requirements of
the ongoing submission requirement
and the active engagement
requirement options included in this
final rule with comment period, we do
not believe that significant time will be
needed to implement the updated
requirement.
For example, in Stage 2 a provider
could register their intent to submit data
to successfully meet a measure in one of
the public health reporting objectives.
Our proposal in the EHR Incentive
Programs for 2015 through 2017
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TABLE 5MEASURES FOR OBJECTIVE 8: PUBLIC HEALTH AND CLINICAL DATA REGISTRY REPORTING OBJECTIVE
Maximum times
measure can
count towards
objective for EP
Measure
Measure
Measure
Measure
Measure
Measure
Measure
1
1
1
2
2
N/A
Maximum times
measure can
count towards
objective for
eligible hospital
or CAH
1
1
1
3
3
1
* EPs, eligible hospitals, and CAHs may choose to report to more than one public health registry to meet the number of measures required to
meet the objective.
** EPs, eligible hospitals, and CAHs may choose to report to more than one clinical data registry to meet the number of measures required to
meet the objective.
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Stage 2 or 2014 Edition rule
requirements. The commenter noted
that adding in this requirement would
require significant development and
implementation effort and that most
states are not yet able to engage in this
functionality.
Response: We appreciate commenters
concerns regarding the addition of a bidirectionality requirement for the EHR
reporting periods covered by the
modified Stage 2 requirements. We
agree with commenters that additional
time may be needed for both public
health agencies and providers to adopt
the necessary technology to support bidirectional functionality. Therefore, we
are not finalizing the bi-directionality
proposal in the EHR Incentive Programs
for 2015 through 2017.
Proposed Measure 2Syndromic
Surveillance Reporting: The EP, eligible
hospital or CAH is in active engagement
with a public health agency to submit
syndromic surveillance data from a nonurgent care ambulatory setting where
the jurisdiction accepts syndromic data
from such settings and the standards are
clearly defined for EPs, or an emergency
or urgent care department for eligible
hospitals and CAHs (POS 23).
Exclusion for EPs: Any EP meeting
one or more of the following criteria
may be excluded from the syndromic
surveillance reporting measure if the
EP
++ Does not treat or diagnose or
directly treat any disease or condition
associated with a syndromic
surveillance system in his or her
jurisdiction;
++ Operates in a jurisdiction for
which no public health agency is
capable of receiving electronic
syndromic surveillance data from EPs in
the specific standards required to meet
the CEHRT definition at the start of the
EHR reporting period; or
++ Operates in a jurisdiction where
no public health agency has declared
readiness to receive syndromic
surveillance data from EPs at the start of
the EHR reporting period.
Exclusion for eligible hospitals/CAHs:
Any eligible hospital or CAH meeting
one or more of the following criteria
may be excluded from the syndromic
surveillance reporting measure if the
eligible hospital or CAH
++ Does not have an emergency or
urgent care department;
++ Operates in a jurisdiction for
which no public health agency is
capable of receiving electronic
syndromic surveillance data from
eligible hospitals or CAHs in the
specific standards required to meet the
CEHRT definition at the start of the EHR
reporting period; or
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inclusion of a variety of registries under
the specialized registry measure,
including Prescription Drug Monitoring
Program reporting and electronic case
reporting. We agree that a variety of
registries may be considered specialized
registries, which allows providers the
flexibility to report using a registry that
is most helpful to their patients.
Therefore, we will continue to allow
these registries to be considered
specialized registries for purposes of
reporting the EHR Reporting period in
2015, 2016, and 2017. However, we will
modify the exclusion not only to reflect
the change from public health registry to
specialized registry but also to allow an
exclusion if the provider does not
collect the data relevant to a specialized
registry within their jurisdiction.
We are also finalizing our proposed
policy to incorporate cancer case
reporting into the measure for EPs only.
Therefore, EPs who were previously
planning to attest to the cancer case
reporting objective, may count that
action toward the Specialized Registry
Reporting measure. We believe this
change is necessary to support
continued provider reporting to cancer
case registries. However, we note that
EPs who did not intend to attest to the
cancer case reporting menu objective are
not required to engage in or exclude
from cancer case reporting in order to
meet the specialized registry reporting
measure. We further note that providers
may use electronic submission methods
beyond the functions of CEHRT to meet
the requirements for the Specialized
Registry Reporting measure. Finally, we
are adopting our proposal that providers
may count the measure more than one
time if they report to multiple
specialized registries as proposed. For
the Stage 3 public health registry
reporting measure within the Public
Health and Clinical Data Registry
Reporting Objective, we direct readers
to section II.B.2.b.viii of this final rule
with comment period.
Proposed Measure 5Clinical Data
Registry Reporting: The EP, eligible
hospital, or CAH is in active
engagement to submit data to a clinical
data registry.
As discussed in the Public Health
Registry Reporting measure, we
proposed to split specialized registry
reporting into two separate, clearly
defined measures: Public health registry
reporting and clinical data registry
reporting. In Stage 2 for EPs, reporting
to specialized registries is a menu
objective and this menu objective
includes reporting to clinical data
registries. For Stage 3, we proposed to
include clinical data registry reporting
as an independent measure. The
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Exclusion for EPs: Any EP meeting
one or more of the following criteria
may be excluded from the syndromic
surveillance reporting measure if the
EP
Is not in a category of providers
from which ambulatory syndromic
surveillance data is collected by their
jurisdictions syndromic surveillance
system;
Operates in a jurisdiction for which
no public health agency is capable of
receiving electronic syndromic
surveillance data from EPs in the
specific standards required to meet the
CEHRT definition at the start of the EHR
reporting period; or
Operates in a jurisdiction where no
public health agency has declared
readiness to receive syndromic
surveillance data from EPs at the start of
the EHR reporting period.
Exclusion for eligible hospitals/CAHs:
Any eligible hospital or CAH meeting
one or more of the following criteria
may be excluded from the syndromic
surveillance reporting measure if the
eligible hospital or CAH
Does not have an emergency or
urgent care department;
Operates in a jurisdiction for which
no public health agency is capable of
receiving electronic syndromic
surveillance data from eligible hospitals
or CAHs in the specific standards
required to meet the CEHRT definition
62825
TABLE 6PUBLIC HEALTH REPORTING OBJECTIVE MEASURES FOR EPS, ELIGIBLE HOSPITALS, AND CAHS IN 2015
THROUGH 2017
Measure specification
The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit immunization data.
The EP, eligible hospital or CAH is in active engagement with a public health agency to submit syndromic surveillance data.
The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit data to a specialized registry.
The eligible hospital or CAH is in active engagement with a public
health agency to submit ELR results.
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1.
2 for EP, 3 for eligible hospital/
CAH.
N/A.
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TABLE 7ELIGIBLE PROFESSIONAL (EP) OBJECTIVES AND MEASURES FOR 2015 THROUGH 2017
Objective 3: Computerized
Provider Order Entry
CPOE.
Objective 6: Patient-Specific
Education.
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62827
TABLE 7ELIGIBLE PROFESSIONAL (EP) OBJECTIVES AND MEASURES FOR 2015 THROUGH 2017Continued
Objectives for 2015, 2016
and 2017
Objective 8: Patient Electronic Access (VDT).
TABLE 8ELIGIBLE HOSPITAL AND CAH OBJECTIVES AND MEASURES FOR 2015 THROUGH 2017
Objectives for 2015, 2016
and 2017
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TABLE 8ELIGIBLE HOSPITAL AND CAH OBJECTIVES AND MEASURES FOR 2015 THROUGH 2017Continued
Objectives for 2015, 2016
and 2017
Objective 2: Clinical Decision Support.
Objective 3: Computerized
Provider Order Entry
CPOE.
Objective 6: Patient-Specific
Education.
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62829
TABLE 8ELIGIBLE HOSPITAL AND CAH OBJECTIVES AND MEASURES FOR 2015 THROUGH 2017Continued
Objectives for 2015, 2016
and 2017
Measure: The eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is admitted to the
eligible hospitals or CAHs inpatient or emergency
department (POS 21 or 23).
Eligible Hospital/CAH Measure 1: More than 50 percent of all unique patients who are discharged from
the inpatient or emergency department (POS 21 or
23) of an eligible hospital or CAH are provided timely
access to view online, download and transmit their
health information to a third party their health information.
Eligible Hospital/CAH Measure 2: For 2015 and
2016: At least 1 patient who is discharged from the
inpatient or emergency department (POS 21 or 23) of
an eligible hospital or CAH (or patient-authorized representative) views, downloads, or transmits to a third
party his or her health information during the EHR reporting period.
For 2017: More than 5 percent of unique patients discharged from the inpatient or emergency department
(POS 21 or 23) of an eligible hospital or CAH (or patient-authorized representative) view, download, or
transmit to a third party their health information during the EHR reporting period.
Not applicable for eligible hospitals and CAHs ..............
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analysis whenever software is updated
is particularly burdensome.
A commenter recommended changing
the requirement of conduct or review
a security risk analysis to conduct
and review a security risk analysis, to
ensure both the behavior and the review
of a security risk analysis will be
completed. Several commenters
requested further clarification of the
timing for completion of the security
risk assessment.
Response: We disagree with the
concept that the objective as proposed is
too comprehensive. We believe that the
proposed addition of administrative and
technical safeguards to this measure
enables providers to implement risk
management security measures to
reduce the risks and vulnerabilities
identified. Administrative safeguards
(for example, risk analysis, risk
management, training, and contingency
plans) and physical safeguards (for
example, facility access controls,
workstation security) are also required
to protect against threats and
impermissible uses or disclosures to
ePHI created or maintained by CEHRT.
The proposed requirement is to
perform the security risk analysis upon
installation of CEHRT or upon upgrade
to a new Edition. Thus, it would be
required when a provider upgraded
from EHR technology certified to the
2014 Edition to EHR technology
certified to the 2015 Edition as
established by ONC. We note that the
second part of the requirement states a
review must be conducted at least on an
annual basis, and additional review may
be required if additional
implementation changes are
subsequently made that were not
included and planned for in the initial
review.
We note that a security risk analysis
is not a discrete item in time, but a
comprehensive analysis covering the
full period of time for which it is
applicable; and the annual review of
such an analysis is similarly
comprehensive. In other words, the
analysis and review are not merely
episodic but should cover a span of the
entire year, including a review planning
for future system changes within the
year or a review of prior system changes
within the year. Therefore, we believe
the commenters concerns may be a
semantic misunderstanding of the
nature of an analysis and annual review.
We proposed to maintain the previously
finalized Stage 2 objective on protecting
ePHI, which includes the statement
conduct or review for both the EHR
Incentive Programs in 2015 through
2017 and for Stage 3.
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prescriptions during the EHR reporting
period; or (2) does not have a pharmacy
within their organization and there are
no pharmacies that accept electronic
prescriptions within 10 miles of the EPs
practice location at the start of his or her
EHR reporting period.
Proposed Eligible Hospital/CAH
Measure: More than 25 percent of
hospital discharge medication orders for
permissible prescriptions (for new and
changed prescriptions) are queried for a
drug formulary and transmitted
electronically using CEHRT.
We proposed to limit this measure for
Stage 3 to only new and changed
prescriptions and invited public
comment on whether a hospital would
issue refills upon discharge for
medications the patient was taking
when they arrived at the hospital and,
if so, whether distinguishing those refill
prescriptions from new or altered
prescriptions is unnecessarily
burdensome for the hospital.
To calculate the percentage, CMS and
ONC have worked together to define the
following for this objective:
Denominator: The number of new or
changed prescriptions written for drugs
requiring a prescription in order to be
dispensed other than controlled
substances for patients discharged
during the EHR reporting period.
Numerator: The number of
prescriptions in the denominator
generated, queried for a drug formulary
and transmitted electronically.
Threshold: The resulting percentage
must be more than 25 percent in order
for an eligible hospital or CAH to meet
this measure.
Exclusion: Any eligible hospital or
CAH that does not have an internal
pharmacy that can accept electronic
prescriptions and there are no
pharmacies that accept electronic
prescriptions within 10 miles at the start
of their EHR reporting period.
In the proposed rule, we recognized
that not every patient will have a
formulary that is relevant to him or her.
If a relevant formulary is available, then
the information can be provided. If there
is no formulary for a given patient, the
comparison could return a result of
formulary unavailable for that patient
and medication combination, and the
provider may count the prescription in
the numerator if they generate and
transmit the prescription electronically
as required by the measure.
Comment: A few commenters were in
support of the e-prescribing objective
because it is an important priority in
quality reporting efforts.
Response: We appreciate the support
and note as we have previously stated,
transmitting the prescription
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providers identify the most valuable
CDS interventions and the most
effective placement of such
interventions in provider workflows.
Response: We offered a list of
workflow optimized information tools
to illustrate some examples in the Stage
3 proposed rule (80 FR 16749). It is not
meant to be list of required tools, nor is
it an exhaustive list of all the options
available. Also in the Stage 3 proposed
rule (80 FR 16750), CMS and ONC have
provided examples of CDS interventions
as well as program models such as
Million Hearts, which may offer
suggestions to providers and raise
awareness of the possibilities available.
CMS and ONC will consider providing
further guidance as to CDS options, CDS
and CQM pairings, and industry
research on various CDS
implementations.
Comment: A commenter requested a
clarification on the relationship between
the functions that are included in the
definition of CEHRT and the actions
that are required for the EHR Incentives
Programs. Some commenters expressed
concern that EPs and eligible hospitals
and CAHs might be limited only to CDS
that ONC had certified. Several
commenters also expressed concern that
the CDS requirements for the EHR
Incentive Program objectives do not
match the standards for certification and
question if the certification
requirements for health IT would limit
the types or utility of CDS a provider
might use to meet the Clinical Decision
Support Objective.
Response: CMS does not certify CDS
functions or resources, but instead
defines that a provider must use CDS
resources and that those resources must
meet the ONC certification criteria to
meet the definition of CEHRT. The EHR
Incentive Programs do not otherwise
restrict a providers ability to choose
any CDS option or resource to meet
their unique needs. For the certification
criteria for CDS, the ONC 2015 Edition
proposed rule (80 FR 16804 through
16921) proposed the functionalities that
health IT developers would build into
their CDS module to meet the
certification criteria. These CDS
modules are what meet the CEHRT
definition for the EHR Incentive
Programs. However, while the
certification rule specifies that the CDS
module that is certified to the CDS
standard must have certain capabilities
to provide or enable CDS for provider
use, it does not certify the supports or
resources themselves. This means that
the ONC health IT certification criteria
are designed to ensure that the CDS
module implemented by EPs and
eligible hospitals and CAHs will enable
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In addition, we proposed to maintain
for Stage 3 that protocol or standing
orders may but are not required to be
excluded from this objective.
We proposed to maintain the Stage 2
description of laboratory services as
any service provided by a laboratory
that could not be provided by a nonlaboratory for the CPOE objective for
Stage 3 (77 FR 53984). We also proposed
to maintain for Stage 3 the Stage 2
description of radiologic services as
any imaging service that uses electronic
product radiation (77 FR 53986). Even
though we proposed to expand the
CPOE objective from radiology orders to
all diagnostic imaging orders, this
description would still apply for
radiology services within the expanded
objective.
We received public comment on our
proposals and our response follows.
Comment: The majority of
commenters supported the inclusion of
this objective. Some of the commenters
appreciated the consistency with the
previous Stage 2 objective. A
commenter requested that we clarify
that there are no changes to the
objective or to the definition of terms
except for diagnostic imaging.
Response: We appreciate the support
for the objective. We proposed to
maintain the Stage 2 CPOE policies
except that the third measure would be
expanded from radiology orders to
diagnostic imaging orders and the
thresholds for the measures would be
increased.
Comment: Commenters requested
clarification of medical staff member
credentialed to perform the equivalent
duties of a credentialed medical
assistant and requested clarification on
a number of potential roles including an
in-house phlebotomist, an
ophthalmological assistant, a medical
student in residency, and other health
care professionals. Other commenters
requested clarification on the phrase
under the direct supervision or active
engagement of a licensed healthcare
professional.
Response: As noted in the Stage 3
proposed rule (80 FR 16751), we require
that the person entering the orders be a
licensed health care professional or
credentialed medical assistant (or staff
member credentialed to the equivalency
and performing the duties equivalent to
a medical assistant). We defer to the
providers discretion to determine the
appropriateness of the credentialing of
staff to ensure that any staff entering
orders have the clinical training and
knowledge required to enter orders for
CPOE.
However, the descriptive phrase
direct supervision or active
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authorized providers of the eligible
hospital or CAH inpatient or emergency
department (POS 21 or 23) during the
EHR reporting period are recorded using
computerized provider order entry;
Denominator: Number of
medication orders created by the EP or
authorized providers in the eligible
hospital or CAH inpatient or emergency
department (POS 21 or 23) during the
EHR reporting period.
Numerator: The number of orders
in the denominator recorded using
CPOE.
Threshold: The resulting percentage
must be more than 60 percent in order
for an EP, eligible hospital, or CAH to
meet this measure.
Exclusion: Any EP who writes
fewer than 100 medication orders
during the EHR reporting period.
Measure 2: More than 60 percent of
laboratory orders created by the EP or
authorized providers of the eligible
hospital or CAH inpatient or emergency
department (POS 21 or 23) during the
EHR reporting period are recorded using
computerized provider order entry; and
Denominator: Number of laboratory
orders created by the EP or authorized
providers in the eligible hospital or
CAH inpatient or emergency department
(POS 21 or 23) during the EHR reporting
period.
Numerator: The number of orders
in the denominator recorded using
CPOE.
Threshold: The resulting percentage
must be more than 60 percent in order
for an EP, eligible hospital, or CAH to
meet this measure.
Exclusion: Any EP who writes
fewer than 100 laboratory orders during
the EHR reporting period.
Measure 3: More than 60 percent of
diagnostic imaging orders created by the
EP or authorized providers of the
eligible hospital or CAH inpatient or
emergency department (POS 21 or 23)
during the EHR reporting period are
recorded using computerized provider
order entry.
Denominator: Number of diagnostic
imaging orders created by the EP or
authorized providers in the eligible
hospital or CAH inpatient or emergency
department (POS 21 or 23) during the
EHR reporting period.
Numerator: The number of orders
in the denominator recorded using
CPOE.
Threshold: The resulting percentage
must be more than 60 percent in order
for an EP, eligible hospital, or CAH to
meet this measure.
Exclusion: Any EP who writes
fewer than 100 diagnostic imaging
orders during the EHR reporting period.
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provider verification process for
enrolling patients; and (4) general
concern over the security of having an
enabled API for an EHR.
Response: It is recognized that APIs
and VDT provide access to sensitive
health care material and security and
privacy of patients ePHI is of utmost
importance. As has been seen in other
industries where system interoperability
has enabled considerable benefits for
the consumer, security technology is
constantly evolving to meet the
changing environment. Thus, detailed
monitoring, penetration testing, audits,
and key management are all necessities.
In addition, this changing environment
requires similarly nimble guidelines and
standards for privacy and security
protocols. The EHR Incentive Program
includes an Objective to Protect Patient
Health Information (see also section
II.B.2.b.1 of this final rule with
comment period). This objective
includes a measure requiring providers
to conduct or review a security risk
analysis in accordance with HIPAA
requirements to ensure the protection of
patient ePHI created or maintained by
CEHRT. This requirement to conduct
and review a security risk analysis
would include the certified API enabled
as a part of the providers CEHRT. This
analysis must also be done in
compliance with HIPAA Security Rules,
which would likewise be applicable to
the provider actions related to the
provision of access to the patients
health information. Beyond this
baseline, we believe that evidence in
similar technological transitions
illustrates the need for a balanced and
responsive approach to privacy and
security. As noted previously, we
encourage providers to innovate around
enrollment structures for patients to
provide accountability for privacy and
security standards; we encourage
developers to incorporate security best
practices in their design; and we
encourage patients to employ sound
practices just as they would with their
online banking or other online activities
regarding personal information.
Comment: Many commenters
expressed concerns about successfully
meeting the objective because their
patient population is elderly, ill, lowincome, and/or located in remote, rural
areas. These patients do not have access
to computers, Internet and/or email and
are concerned with having their health
information online. A commenter
specifically requested that clinics with
high elderly populations, especially
those in rural areas, be exempt from
meeting these patient electronic access
requirements. Another commenter
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the individual patient to other provider
organizations, non-physician care
settings, home health care, and many
other uses. We recognize that under
very high usage, it may be expensive to
support APIs, and in those
circumstances, providers may want to
consider the feasibility of cost sharing
arrangements with outside organizations
or businesses, which frequently leverage
the enabled API to support care
coordination.
Comment: A few comments focused
on Measure 2, the requirement to
provide CEHRT-generated patient
educational materials to patients. A
commenter discussed how low patient
adoption of portals/APIs makes it
difficult to provide more than 35
percent of patients with electronic
educational materials. Another
commenter requested that(1) the
denominator be patients who have
office visits rather than patients who are
seen by an EP; and (2) providers who
have less than 100 office visits during
the EHR reporting period be excluded.
Lastly, a commenter opposed only using
CEHRT-generated patient educational
materials and thought additional
materials printed in-office by providers
should be acceptable.
Response: We disagree that this
measure threshold should be reduced or
limited to office visits or that providers
should be required or allowed to
continue to count paper-based actions
toward this measure. We believe that
the provision of access to patientspecific education following a similar
model as the provision of access to a
patients record will allow providers the
opportunity to leverage a wide range of
resources for patients and include this
information in concert with the patients
electronic health record. We believe that
as the technology continues to evolve
providers will perform well beyond the
threshold and expect that innovative
options will progress apace with this
progress. We by no means intend to
discourage providers from also using
paper-based or other methods of
providing patients with education about
their health and their care. We are
simply no longer requiring or allowing
paper-based actions to be counted
because the EHR Incentive Programs
focuses on leveraging health IT to
support patient engagement.
We are therefore finalizing Measure 2
as proposed for the method of delivery
and with a modification to specify that
for the numerator of for measure 2 for
each year, the action must occur within
the same calendar year as the EHR
reporting period, but may occur before,
during, or after the EHR reporting
period if the EHR reporting period for
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objectives related to providing patients
with access to health information into a
new Stage 3 objective entitled, Patient
Electronic Access (see section
II.B.2.b.v). For this objective 6 entitled
Coordination of Care through Patient
Engagement, we proposed to
incorporate the policy goals of the Stage
2 objectives related to secure messaging,
patient reminders, and the measure of
patient engagement requiring patients
(or their authorized representatives) to
view, download, and transmit their
health information using the
functionality of the CEHRT.
Proposed Objective: Use
communications functions of CEHRT to
engage with patients or their authorized
representatives about the patients care.
The Stage 3 proposed rule focused on
encouraging the use of EHR
functionality for secure dialogue and
efficient communication between
providers, care team members, and
patients about their care and health
status, as well as important health
information such as preventative and
coordinated care planning. Similar to
the Patient Electronic Access Objective,
we also proposed to expand the options
through which providers may engage
with patients under the Medicare and
Medicaid EHR Incentive Programs
including the use of APIs. An API can
enable a patientthrough a third-party
applicationto access and retrieve their
health information from a care provider
in a way that is most valuable to that
patient. We proposed the Coordination
of Care through Patient Engagement
Objective for Stage 3 to support this
provider and patient engagement
continuum based on the foundation
already created within the EHR
Incentive Programs but using new
methods and expanded options to
advance meaningful patient engagement
and patient-centered care. We also
proposed that for purposes of this
objective, patient engagement may
include patient-centered
communication between and among
providers facilitated by authorized
representatives of the patient and of the
EP, eligible hospital, or CAH.
We proposed three measures for this
objective, which are discussed below.
We proposed that providers must attest
to the numerator and denominator for
all three measures, but would only be
required to successfully meet the
threshold for two of the three proposed
measures to meet the Coordination of
Care through Patient Engagement
Objective.
Comment: Commenters supported the
concept of patient engagement and
promoting communication among
provider and patients. Also,
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Exclusion: Any EP who has no office
visits during the EHR reporting period
may exclude from the measure.
Any EP that conducts 50 percent or
more of his or her patient encounters in
a county that does not have 50 percent
or more of its housing units with 4Mbps
broadband availability according to the
latest information available from the
FCC on the first day of the EHR
reporting period may exclude from the
measure.
Any eligible hospital or CAH
operating in a location that does not
have 50 percent or more of its housing
units with 4Mbps broadband
availability according to the latest
information available from the FCC on
the first day of the EHR reporting period
may exclude from the measure.
For measure 2, we proposed that
communicate means when a provider
sends a message to a patient (or the
patients authorized representatives) or
when a patient (or the patients
authorized representatives) sends a
message to the provider. In patient-toprovider communication, the provider
must respond to the patient (or the
patients authorized representatives) for
purposes of this measure. We further
proposed to include in the measure
numerator situations where providers
communicate with other care team
members using the secure messaging
function of CEHRT, and the patient is
engaged in the message and has the
ability to be an active participant in the
conversation between care providers.
However, we sought comment on how
this action could be counted in the
numerator, and the extent to which that
interaction could or should be counted
for eligible providers engaged in the
communication. In addition, we sought
comment on what should be considered
a contribution to the patient-centered
communication; for example, a
contribution must be active
participation or response, a contribution
may be viewing the communication, or
a contribution may be simple inclusion
in the communication.
We specified that the secure messages
sent should contain relevant health
information specific to the patient in
order to meet the measure of this
objective. We believe the provider is the
best judge of what health information
should be considered relevant in this
context. We noted that messages with
content exclusively relating to billing
questions, appointment scheduling, or
other administrative subjects should not
be included in the numerator. For care
team secure messaging with the patient
included in the conversation, we also
believe the provider may exercise
discretion if further communications
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communications, provider-to-provider
communications if the patient is
included, and allows the provider to
count any patient-initiated
communication if the provider responds
to the patient (80 FR 16757). We
disagree that the provider should not be
required to respond to the patient in
order to meet the measure, the goal of
the measure is to promote providerpatient communication where the action
driving the communication rests with
provider initiated communication. We
note that this does not require the
provider to respond to every message
received if no response is necessary. In
addition, the denominator is not based
on the number of messages received
from the patient nor are patient-initiated
messages required to meet the measure.
Therefore we believe that it is
reasonable to only allow providers to
count messages in the numerator when
the provider participates in the
communication, in this case by
responding to the patient.
Again, we do agree that the threshold
should represent a goal, but that we
should seek to set a goal that will be
attainable for providers who make the
effort to achieve this measure. As
discussed for Measure 1, we adopted a
phased approach for the two measures
related to patient action for reporting in
2015 through 2017 (Objective 8Patient
Electronic Access measure 2 and the
Objective 9Secure Electronic
Messaging.) This phased approach
includes a 5 percent threshold in 2017
and we believe it is appropriate to adopt
a 5 percent threshold for measures 2 of
this objective (Stage 3 Objective 6
Coordination of Care through Patient
Engagement) for an EHR reporting
period in 2017. In this case, it is not the
barrier of patient action which is a
potential risk factor, as the measure
itself has been changed, but instead the
adoption of new CEHRT and
implementing the related workflows
which would be required for providers
participating in Stage 3 in 2017. We also
believe a 25 percent threshold would be
an attainable goal for providers in 2018
because the measure focuses on
provider-initiated action and offers
multiple paths for success; while the
reduction from 35 percent reduces the
risk of failure for those providers who
may require additional time to
implement the functions and workflows
within their practice. As stated in the
Stage 3 proposed rule (80 FR 16757), the
types of communications which cannot
count toward the measure are
communications dealing exclusively
with billing, appointment scheduling, or
other administrative processes.
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providers such as nutritionists, physical
therapists, occupational therapists,
psychologists, and home health care
providers. Other key providers in the
care team such as behavioral health care
providers, may also be included, and we
encourage providers to consider ways in
which this measure can incorporate this
essential information from the broader
care team. We also note, as stated in the
Stage 3 proposed rule, while the scope
of data covered by this proposed
measure is broad, it may not include
data related to billing, payment, or other
insurance information (80 FR 16757).
We also disagree with the suggestion
that the data may be information the
patient provides to the EP, eligible
hospital or CAH on location during the
office visit or hospital stay as such data
does not meet the intent of the measure
to support care coordination and patient
engagement in a wide range of settings
outside the providers immediate scope
of practice. However, we agree that if a
patient separately provides clinical
information including family health
history and the information noted
previously through other means, that
such information may count toward the
numerator if it is incorporated into the
patient record using the adopted
specifications for CEHRT for the
measure.
With regard to the efficacy of the data,
we do not specify the manner in which
providers are required to incorporate the
data. Providers may work with their
EHR developers to establish the
methods and processes which work best
for their practice and needs. We note
that in cases where the data provided
can be easily incorporated in a
structured format or into an existing
field within the EHR (such as a CCDA
or care team member reported vital
signs or patient reported family health
history and demographic information)
the provider may elect to do so.
Alternately, a provider may maintain an
isolation between the data and the
patient record and instead include the
data by other means such as
attachments, links, and text references
again as best meets their needs. We
believe there may be a wide range of
potential methods by which a provider
may ensure the data is relevant for their
needs and that provenance and purpose
are identified.
Finally, we note that measure 3
includes longitudinal measurement
within the EHR reporting period, rather
than purely episodic measurement. This
means that for more than 5 percent of
unique patients during the EHR
reporting period, this information must
be included. If information is obtained
and incorporated for a patient following
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but would only be required to
successfully meet the threshold for two
of the three proposed measures to meet
the Health Information Exchange
Objective.
Proposed Measure 1: For more than
50 percent of transitions of care and
referrals, the EP, eligible hospital or
CAH that transitions or refers their
patient to another setting of care or
provider of care: (1) Creates a summary
of care record using CEHRT; and (2)
electronically exchanges the summary
of care record.
Proposed Measure 2: For more than
40 percent of transitions or referrals
received and patient encounters in
which the provider has never before
encountered the patient, the EP, eligible
hospital or CAH incorporates into the
patients EHR an electronic summary of
care document from a source other than
the providers EHR system.
Proposed Measure 3: For more than
80 percent of transitions or referrals
received and patient encounters in
which the provider has never before
encountered the patient, the EP, eligible
hospital, or CAH performs a clinical
information reconciliation. The provider
must implement clinical information
reconciliation for the following three
clinical information sets:
Medication. Review of the patients
medication, including the name, dosage,
frequency, and route of each
medication.
Medication allergy. Review of the
patients known medication allergies.
Current Problem list. Review of the
patients current and active diagnoses.
For the first measure, we maintained
the requirements established in the
Stage 2 final rule to capture structured
data within the certified EHR and to
generate a summary of care document
using CEHRT for purposes of this
measure (77 FR 54014). For purposes of
this measure, we required that the
summary of care document created by
CEHRT be sent electronically to the
receiving provider.
In the Stage 2 final rule at 77 FR
54016, we specified all summary of care
documents must include the following
information in order to meet the
objective, if the provider knows it:
Patient name.
Referring or transitioning providers
name and office contact information (EP
only).
Procedures.
Encounter diagnosis.
Immunizations.
Laboratory test results.
Vital signs (height, weight, blood
pressure, BMI).
Smoking status.
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reconciliation as the process of creating
the most accurate patient-specific
information in one or more of the
specified categories using the clinical
information reconciliation capability of
certified EHR technology, which will
compare the local information to
external/incoming information that is
being incorporated into the certified
EHR technology from any external
source. We referred providers to the
standards and certification criteria for
clinical information reconciliation
proposed in ONCs 2015 Edition
proposed rule at 80 FR 16831 through
16833.
As with medication reconciliation, we
believe that an electronic exchange of
information following the transition of
care of a patient is the most efficient
method of performing clinical
information reconciliation.
We recognized that workflows to
reconcile clinical information vary
widely across providers and settings of
care, and we requested comment on the
challenges that this objective might
present for providers, and how such
challenges might be mitigated, while
preserving the policy intent of the
measure. In particular, we solicited
comment on the following:
Automation and Manual
Reconciliation. The Stage 2 measure
does not specify whether reconciliation
must be automated or manual. Some
providers have expressed concern over
the automatic inclusion of data in the
patient record from referring providers,
while others have indicated that
requiring manual reconciliation imposes
significant workflow burden. We also
sought comment on whether the use and
display of meta-tagged data could
address concerns related to the origin of
data and thereby permit more
automated reconciliation of these data
elements.
Review of Reconciled Information.
Depending on clinical setting, this
measure could be accomplished through
manual reconciliation or through
automated functionality. In either
scenario, should the reconciliation or
review of automated functionality be
performed only by the same staff
allowed under the Stage 3 requirements
for the CPOE objective?
What impact would the
requirement of clinical information
reconciliation have on workflow for
specialists? Are there particular
specialties where this measure would be
difficult to meet?
What additional exclusions, if any,
should be considered for this measure?
We also encouraged comment on the
proposal to require reconciliation of all
three clinical information reconciliation
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measure.18 We also note that, as stated
in the proposed rule, we define a
transition of care or referral as a
transition or referral to another provider
of care that is recognized as a different
billing entity for the EHR Incentive
Programs (NPI, CCN). The inclusion or
exclusion of additional provider types
and transitions or referrals is at the
discretion of the provider as best meets
their practice needs as long as the
inclusion or exclusion policy is applied
universally for the duration of the EHR
reporting period.
We intend to support policies that
mitigate the impact that a lack of trading
partners or a lack of transport
mechanisms have on providers. As we
note throughout this final rule with
comment period, we are seeking to
increase participation among EHR
Incentive Program participants and
expand the methods by which providers
may exchange information. These
policies are aimed at ensuring that a
lack of trading partners will not
continue to be a significant hurdle for
providers as the widespread adoption of
certified EHRs continues and new
flexible innovations for transport are
supported.
In addition, CMS and ONC share a
mutual understanding of the issue
relating to importance of provider
access to health information exchange
contact information and agree that a
method to facilitate this access would
support interoperable health
information exchange. We are
committed to exploring potential
models and opportunities to enable
providers to more readily share their
own electronic exchange contact
information and access the contact
information of potential trading
partners. It is our intent to populate the
National Plan and Provider
Enumeration System (NPPES) with
direct addresses and/or electronic
service endpoints of EHR Incentive
Program participants as a means of
creating a health care provider directory
resource. For more information, we
direct readers to section II.D.3 of this
final rule with comment period.
Comment: Many commenters
requested a clearer definitions for the
denominators relating to the measures
including:
Transitions of care for providers
with a shared EHR
Patient-reported referrals and
patient self-referrals
New patients and patient
encounters in which the provider has
never before encountered the patient
18 ONC
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The 2015 Edition proposed rule also
included a criterion to record a patients
sexual orientation and gender identity
(SO/GI) in a structured way with
standardized data. Where the patient
chooses to disclose this information, the
inclusion of this information can help
those within the patients care team to
have more information on the patient
that can aid in identifying interventions
and treatments most helpful to the
particular patient. Additionally, sexual
orientation and gender identity can be
relevant to individual treatment
decisions; for example, transgender men
who were assigned female at birth
should be offered a cervical exam, as
appropriate. In the final rule, ONC is
requiring that Health IT modules enable
a user to record, change, and access SO/
GI to be certified to the 2015 Edition
demographics certification criterion.
By doing so, SO/GI is now included in
the 2015 Edition Base EHR definition,
which is a part of the definition of
CEHRT (see section II.B.3). We note that
certification does not require that a
provider collect this information; it
requires only that their CEHRT enable
the provider to do so. CMS and ONC
believe including SO/GI in the
demographics criterion represents a
crucial step forward to improving care
for LGBT communities.
We also note that we received
comments specific to the composition of
the CCDS and addressing the CCDA,
which are out of scope for this rule. We
refer readers to the 2015 Edition final
rule included elsewhere in this Federal
Register for further information on the
CCDS and the CCDA, as well as for
further information on provisions
related to data collection, including the
collection of sexual orientation and
gender identity data and behavioral,
social, and psychological data.
Comment: For Measure 1, many
commenters expressed similar concerns
with the first measure as with HIE as a
whole citing interoperability barriers
and the lack of providers and other
trading partners available to
electronically exchange data.
Commenters also considered the
threshold of 50% to be too high and too
far a leap from the 10% requirement in
Stage 2. Additionally, commenters
opposed removing the exclusion
qualifier which allowed providers to
exclude the measure if they conduct
fewer than 100 referrals or transitions of
care during the EHR reporting period. A
few commenters believe measure 1 is
valuable driver of interoperability
within health care, but acknowledged
that refinements/adjustments need to be
made.
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reviewed by a provider in a timely
manner.
Other commenters stated that not all
new patient referrals require
comprehensive data reconciliation. For
example a dermatologist evaluating a
simple skin lesion or an orthopedist
evaluating a painful joint may not need
to perform in depth reconciliation to
provide quality care.
In addition, many commenters
discussed the means of measurement for
medications, problems, and allergies
such as if duplicate records needed to
be reconciled or if data that is verified
as requiring no further update would
also count toward the measure. Several
commenters requested clarification on
whether the reconciliation should be
automated or manual. Some requested
we offer both options to allow providers
to choose the means that best fits their
practice, and many commenters had
concerns about the liability associated
with automated reconciliation.
Response: We appreciate the support
for the measure; however, we did not
propose that this measure should be
required for the objective but rather that
providers must meet the threshold for
two of three measures based on the
needs of their practice. We believe that
many providers may conduct some form
of reconciliation in conjunction with
measure 2, or that providers in certain
specialties may elect to conduct
reconciliation of clinical information
even beyond our requirement at all
patient encounters. We understand from
previous listening sessions and feedback
from stakeholders that the summary of
care documents sometimes contain an
overwhelming amount of information.
For this reason, we allow provider
discretion to define the relevant clinical
notes and/or laboratory results to send
in the summary of care document,
although we maintain that providers
must still have the CEHRT functionality
to include and send all labs or clinical
notes. We believe this will provide the
efficiency sought by stakeholders in
their feedback.
We note that this measure builds on
the existing Medication Reconciliation
Objective for the EHR Incentive
Programs in 2015 through 2017 (see
section II.B.2.a.v). We agree that this
process may include both automated
and manual reconciliation to allow the
receiving provider to work with both the
electronic data provided with any
necessary review, and to work directly
with the patient to reconcile their health
information. We further note that the
point of reconciliation is to assist in
maintaining the most relevant,
complete, and up to date information for
a given patient. If no update is
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ongoing submission requirement does
not accurately capture the nature of
communication between providers and
a public health agency or clinical data
registry, and does not consider the many
steps necessary to arrange for registry
submission to a public health agency or
clinical data registry. Given this
feedback, we believe that active
engagement as defined later in this
section is more aligned with the process
providers undertake to report to a
clinical data registry or to a public
health agency.
For purposes of meeting this new
objective, EPs, eligible hospitals and
CAHs would be required to demonstrate
that active engagement with a public
health agency or clinical data registry
has occurred. Active engagement means
that the provider is in the process of
moving towards sending production
data to a public health agency or
clinical data registry, or is sending
production data to a public health
agency or clinical data registry. We
noted that the term production data
refers to data generated through clinical
processes involving patient care and it
is used to distinguish between this data
and test, data which may be
submitted for the purposes of enrolling
in and testing electronic data transfers.
We proposed that active engagement
may be demonstrated by any of the
following options:
Active Engagement Option 1
Completed Registration to Submit Data:
The EP, eligible hospital, or CAH
registered to submit data with the public
health agency or, where applicable, the
clinical data registry to which the
information is being submitted;
registration was completed within 60
days after the start of the EHR reporting
period; and the EP, eligible hospital, or
CAH is awaiting an invitation from the
public health agency or clinical data
registry to begin testing and validation.
This option allows providers to meet the
measure when the public health agency
or the clinical data registry has limited
resources to initiate the testing and
validation process. Providers that have
registered in previous years do not need
to submit an additional registration to
meet this requirement for each EHR
reporting period.
Active Engagement Option 2Testing
and Validation: The EP, eligible
hospital, or CAH is in the process of
testing and validation of the electronic
submission of data. Providers must
respond to requests from the public
health agency or, where applicable, the
clinical data registry within 30 days;
failure to respond twice within an EHR
reporting period would result in that
provider not meeting the measure.
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TABLE 9MEASURES FOR OBJECTIVE 8: PUBLIC HEALTH AND CLINICAL DATA REGISTRY REPORTING OBJECTIVE
Measure
Measure
Measure
Measure
Measure
Measure
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Maximum
times measure
can count towards objective for EP
Maximum
times measure
can count towards objective for eligible
hospital or
CAH
1
1
1
3
3
1
1
1
4
4
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TABLE 9MEASURES FOR OBJECTIVE 8: PUBLIC HEALTH AND CLINICAL DATA REGISTRY REPORTING OBJECTIVE
Continued
Measure
Maximum
times measure
can count towards objective for EP
Maximum
times measure
can count towards objective for eligible
hospital or
CAH
N/A
* EPs, eligible hospitals, and CAHs may choose to report to more than one public health registry to meet the number of measures required to
meet the objective.
** EPs, eligible hospitals, and CAHs may choose to report to more than one clinical data registry to meet the number of measures required to
meet the objective.
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the time burden to report can also
contribute to low reporting compliance.
However, electronic case reporting
presents a core benefit to public health
improvement and a variety of
stakeholders identified electronic case
reporting as a high value element of
patient and continuity of care. Further,
we believe that electronic case reporting
reduces burdensome paper-based and
labor-intensive case reporting.
Electronic reporting will support more
rapid exchange of case reporting
information between public health
agencies and providers and can include
structured questions or data fields to
prompt the provider to supply
additional required or care-relevant
information.
Proposed Exclusion for Measure 3:
Any EP, eligible hospital, or CAH
meeting one or more of the following
criteria may be excluded from the case
reporting measure if the EP, eligible
hospital, or CAH: (1) Does not treat or
diagnose any reportable diseases for
which data is collected by their
jurisdictions reportable disease system
during the EHR reporting period; (2)
operates in a jurisdiction for which no
public health agency is capable of
receiving electronic case reporting data
in the specific standards required to
meet the CEHRT definition at the start
of the EHR reporting period; or (3)
operates in a jurisdiction where no
public health agency has declared
readiness to receive electronic case
reporting data at the start of the EHR
reporting period.
Comment: For Measure 3,
commenters overwhelmingly supported
the need for electronic case reporting.
Many comments expressed concern
with the standards referenced and the
immaturity to perform these functions,
especially the ability of public health
jurisdictions to accept data during the
EHR Incentive program for 2015 through
2017. Some commenters noted their
support for case reporting, including its
potential impact on patient outcomes
and the use of data elements for
reporting. Another commenter
supported the measure, but noted the
importance of ensuring high quality
data and sufficient funding for public
health agencies to accept data
transmissions.
Response: We note that we did not
finalize the case reporting option for the
EHR Incentive Program in 2015 through
2017 to allow additional time for the
development of the technology and
infrastructure to support the measure.
We also, as described elsewhere in this
final rule with comment period and as
noted in the Stage 2 final rule, we did
allow case reporting to continue to
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or CAH may report to more than one
clinical data registry to meet the total
number of required measures for this
objective. We further noted that ONC
will consider the adoption of standards
and implementation guides in future
rulemaking and should these be
finalized, they may then be adopted as
part of the certified EHR technology
definition as it relates to meeting the
clinical data registry reporting measure
through future rulemaking for the EHR
Incentive Programs.
Proposed Exclusions for Measure 5:
Any EP, eligible hospital, or CAH
meeting at least one of the following
criteria may be excluded from the
clinical data registry reporting measure
if the EP, eligible hospital, or CAH: (1)
Does not diagnose or directly treat any
disease or condition associated with a
clinical data registry in their jurisdiction
during the EHR reporting period; (2)
operates in a jurisdiction for which no
clinical data registry is capable of
accepting electronic registry
transactions in the specific standards
required to meet the CEHRT definition
at the start of the EHR reporting period;
or (3) operates in a jurisdiction where
no clinical data registry for which the
EP, eligible hospital, or CAH is eligible
has declared readiness to receive
electronic registry transactions at the
beginning of the EHR reporting period.
Comment: Many commenters noted
their support for clinical data registries.
Commenters appreciated the flexibility
and additional means to meet the
measure, which they noted aids
specialists. Nearly all commenters
expressed specific support for the
Centralized Readiness Repository noting
that it is essential for providers to
determine if they can attest to the
measure of if they should take an
exclusion. Commenters also noted the
specific content that should be available
within the Centralized Readiness
Repository.
Response: We appreciate the overall
support for this measure. We agree that
this measure offers flexibility for
specialists and as other clinical data
registry standards mature, additional
options will be available. We also
appreciate the support for the
Centralized Readiness Repository and
will make note of the specific
requirements made by commenters,
including the requirement for national
as well as local and state public health
registries.
Comment: A commenter noted that
since an increasing number of clinical
data registries are national in scope and
are essentially borderless, it is unclear
how CMS would define a providers
jurisdiction.
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jurisdiction for which no public health
agency is capable of receiving electronic
case reporting data in the specific
standards required to meet the CEHRT
definition at the start of the EHR
reporting period; or (3) operates in a
jurisdiction where no public health
agency has declared readiness to receive
electronic case reporting data as of 6
months prior to the start of the EHR
reporting period.
Measure 4Public Health Registry
Reporting: The EP, eligible hospital, or
CAH is in active engagement with a
public health agency to submit data to
public health registries.
Exclusions for Measure 4: Any EP,
eligible hospital, or CAH meeting at
least one of the following criteria may
be excluded from the public health
registry reporting measure if the EP,
eligible hospital, or CAH: (1) Does not
diagnose or directly treat any disease or
condition associated with a public
health registry in their jurisdiction
during the EHR reporting period; (2)
operates in a jurisdiction for which no
public health agency is capable of
accepting electronic registry
transactions in the specific standards
required to meet the CEHRT definition
at the start of the EHR reporting period;
or (3) operates in a jurisdiction where
no public health registry for which the
EP, eligible hospital, or CAH is eligible
has declared readiness to receive
62871
TABLE 10MEASURES FOR OBJECTIVE 8: PUBLIC HEALTH AND CLINICAL DATA REGISTRY REPORTING OBJECTIVE
Measure
Measure
Measure
Measure
Measure
Measure
Measure
Maximum
times measure
can count
towards
objective
for EP
Maximum
times measure
can count
towards
objective
for eligible
hospital or
CAH
1
1
1
2
2
N/A
1
1
1
4
4
1
* EPs, eligible hospitals, and CAHs may choose to report to more than one public health registry to meet the number of measures required to
meet the objective. A specialized registry to which the EP, eligible hospital or CAH reported using Active Engagement Option 3: Production in a
prior year under the EHR Incentive Programs in 2015 through 2017 public health reporting objective may also count toward the measure in 2017,
2018 and subsequent years.
** EPs, eligible hospitals, and CAHs may choose to report to more than one clinical data registry to meet the number of measures required to
meet the objective.
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comment period, developers and
providers will have more than 24
months to develop and implement 2015
Edition technology required by this final
rule with comment period.
Further, we note that many of the
requirements of Stage 3 are similar to
those of Stage 2 and would use the same
certification criteria with slight updates
to vocabulary standards. For those
criteria that are new to meaningful use
in Stage 3 or for which significant
updates are required, we agree with
developers who confirm that 18 to 24
months provide enough time to develop
and implement certified technology for
purposes of meaningful use. We refer
readers to section III.A. Table 2 of the
ONC 2015 Edition Certification Criteria
final rule published elsewhere in this
Federal Register for further information
on the differences between 2014 Edition
and 2015 Edition criteria.
We further note that 2018 is the
required year for the use of 2015 Edition
and for attesting to Stage 3. We
proposed and are finalizing in this rule
a 2017 flex year that allows providers
options in the edition of CEHRT used
and the stage of meaningful use to
which the provider attests. This
flexibility is in place in recognition of
the implementation needed for
technology. However, by 2018, all
providers will be required to attest to
Stage 3 using 2015 Edition technology.
Comment: Some commenters
requested clarification on if a provider
would be required to be certified to
technology needed for measures the
provider does not intend to use for
attestation or if there is a specific
certification requirement for certain
specialties.
Response: ONC certifies products not
by specialty, but by each specific
functionality. In some cases, intended
impatient or ambulatory use may be a
factor in the product a provider chooses
to possess. Beyond this distinction, the
definition of CEHRT includes the
requirements specific to each measure
which may be independently certified
and a provider may not be required to
obtain and use functions for which they
do not intend to attest. We recognize
that there are multiple permutations
that could lead to a successful
attestation under the EHR Incentive
Programs. For example, a provider may
decide to attest to the modified Stage 2
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TABLE 11EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR 2015 THROUGH 2017
Objective
Measure(s)
2014 edition
Objective 1: Protect
Patient Health Information.
170.314(a)(8) (Clinical
Decision Support).
170.315(a)(9) (Clinical
Decision Support).
N/A.
N/A.
N/A.
N/A.
170.315(b)(3) (Electronic
Prescribing).
170.315(a)(10) (DrugFormulary and Preferred
Drug List Checks).
170.315(b)(1) (Transitions of Care).
N/A.
N/A.
170.315(e)(1) (View,
Download, and Transmit
to 3rd Party).
N/A.
Objective 2: Clinical
Decision Support.
Measure 2: More than 30% of laboratory orders created by the EP during the EHR reporting period are recorded using CPOE.
Measure 3: More than 30% of radiology orders created by the EP during the EHR reporting period are recorded using CPOE.
Objective 4: Electronic
Prescribing.
Objective 8: Patient
Electronic Access
(VDT).
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Measure 1: More than 50%of all unique patients seen by the EP during the EHR reporting period are provided timely access
to view online, download, and transmit to a
third party their health information subject
to the EPs discretion to withhold certain
information.
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Additional considerations
N/A.
N/A.
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TABLE 11EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR 2015 THROUGH 2017Continued
Objective
Objective 9: Secure
Messaging.
Measure(s)
2014 edition
2015 edition
170.314(e)(1) (View,
Download, and Transmit
to 3rd Party).
170.315(e)(1) (View,
Download, and Transmit
to 3rd Party).
N/A.
170.314(e)(3) (Secure
Messaging).
170.315(e)(2) (Secure
Messaging).
N/A.
N/A ....................................
N/A.
N/A.
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TABLE 12ELIGIBLE HOSPITAL AND CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR 2015 THROUGH
2017
Objective
Measure(s)
Objective 3: Computerized
Provider Order Entry
CPOE.
2014 Edition
Objective 6: Patient-Specific
Education.
Objective 7: Medication
Reconciliation.
VerDate Sep<11>2014
Measure: More than 10% of hospital discharge medication orders for permissible prescriptions (for new or changed
prescriptions) are queried for a drug formulary and transmitted electronically
using CEHRT.
Measure: The eligible hospital or CAH that
transitions or refers their patient to another setting of care or provider of care
(1) uses CEHRT to create a summary
of care record; and (2) electronically
transmits such summary to a receiving
provider for more than 10% of transitions of care and referrals.
Measure: More than 10% of all unique patients admitted to the eligible hospitals
or CAHs inpatient or emergency department (POS 21 or 23) are provided
patient specific education resources
identified by CEHRT.
Measure: The eligible hospital or CAH
performs medication reconciliation for
more than 50% of transitions of care in
which the patient is admitted to the eligible hospitals or CAHs inpatient or
emergency department (POS 21 or 23).
Measure 1: More than 50 percent of all
unique patients who are discharged
from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH are provided timely access
to view online, download and transmit
their health information to a third party
their health information.
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Additional considerations
N/A.
170.314(a)(2) (Drug-drug,
Drug-Allergy Interaction
Checks).
170.315(a)(4) (Drug-drug,
Drug-Allergy Interaction
Checks for CPOE).
N/A.
N/A.
N/A.
N/A.
170.315(b)(3) (Electronic
Prescribing).
170.315(a)(10) (Drug-Formulary and Preferred
Drug List Checks).
170.314(b)(2) (Transitions
of Care-Create and
Transmit Transition of
Care/Referral Summaries)
or
170.314(b)(8) (Optional
Transitions of care).
170.315(b)(1) (Transitions
of Care).
N/A.
N/A.
N/A.
170.315(e)(1) (View,
Download, and Transmit
to 3rd Party).
N/A.
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62879
TABLE 12ELIGIBLE HOSPITAL AND CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR 2015 THROUGH
2017Continued
Objective
Measure(s)
2014 Edition
2015 Edition
Additional considerations
170.314(e)(1) (View,
Download, and Transmit
to 3rd Party).
170.315(e)(1) (View,
Download, and Transmit
to 3rd Party).
N/A.
N/A ......................................
N/A ......................................
N/A.
N/A ......................................
N/A.
N/A.
170.314(f)(4) (Inpatient
Setting OnlyTransmission of Reportable
Laboratory Tests and Values/Results.
N/A.
TABLE 13EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017
Objective
Measure(s)
VerDate Sep<11>2014
2014 Edition
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Combinations
170.314(b)(3) (Electronic
Prescribing)
170.314(a)(10) (Drug-Formulary and Preferred
Drug List Checks).
170.314(a)(8) (Clinical Decision Support).
170.315(b)(3) (Electronic
Prescribing).
170.315(a)(10) (Drug-Formulary and Preferred
Drug List checks).
170.315(a)(9) (Clinical Decision Support).
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N/A.
62880
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TABLE 13EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017Continued
Objective
Objective 4: Computerized
Provider Order Entry
(CPOE).
Measure(s)
2014 Edition
2015 Edition
Measure 2: The EP has enabled and implemented the functionality for drug
drug and drugallergy interaction
checks for the entire EHR reporting period.
Measure 1: More than 60% of medication
orders created by the EP during the
EHR reporting period are recorded
using CPOE.
170.314(a)(2) (Drug-Drug,
Drug-Allergy Interaction
Checks).
170.315(a)(4) (Drug-Drug,
Drug-Allergy Interaction
Checks for CPOE).
N/A.
N/A.
N/A.
Measure 2: The EP must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access
to those materials to more than 35% of
unique patients seen by the EP.
Measure 1: For 2017, during the EHR reporting period, more than 5% of all
unique patients(or patient-authorized
representative)seen by the EP actively
engage with the EHR made accessible
by the provider. An EP may meet the
measure by either
(1) view, download or transmit to a third
party their health information; or.
(2) access their health information through
the use of an API that can be used by
applications chosen by the patient and
configured to the API in the providers
CEHRT; or (3) a combination of (1) and
(2).
170.314(e)(1) (View,
Download, and Transmit
to 3rd Party).
170.315(e)(1) (View,
Download, and Transmit
to 3rd Party).
170.315(g)(7) (Application
AccessPatient Selection) *.
170.315(g)(8) (Application
AccessData Category
Request) *.
170.315(g)(9) (Application
AccessAll Data Request) *.
* The three criteria combined are the API certification criteria.
170.314(e)(3) (Secure
Messaging).
170.315(e)(2) (Secure
Messaging).
Objective 6: Coordination of
Care through Patient Engagement.
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Combinations
170.315(a)(3) (ComputerN/A.
ized Provider Order
EntryDiagnostic Imaging).
170.315(e)(1) (View,
Download, and Transmit
to 3rd Party).
170.315(g)(7) (Application
AccessPatient Selection) *.
170.315(g)(8) (Application
AccessData Category
Request) *.
170.315(g)(9) (Application
AccessAll Data Request) *.
* The three criteria combined are the API certification criteria.
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62881
TABLE 13EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017Continued
Objective
Measure(s)
2014 Edition
2015 Edition
N/A ......................................
Measure 1: For more than 50% of transitions of care and referrals, the EP that
transitions or refers their patient to another setting of care or provider of
care(1) creates a summary of care
record using CEHRT; and (2) electronically exchanges the summary of care
record.
Measure 2: For more than 40% of transitions or referrals received and patient
encounters in which the EP has never
before encountered the patient, the EP
receives or retrieves and incorporates
into the patients record an electronic
summary of care document.
Measure 3: For more than 80% of transitions or referrals received and patient
encounters in which the EP has never
before encountered the patient, the EP
performs clinical information reconciliation.
170.314(b)(2) (Transitions
of CareCreate and
Transmit Transition of
Care/Referral Summaries)
or
170.314(b)(8) (Optional
Transitions of Care).
170.315(e)(3) (Patient
Health Information Capture) *.
* Supports meeting the
measure, but is NOT required to be used to meet
the measure. The certification criterion is part of
the CEHRT definition beginning in 2018.
170.315(b)(1) (Transitions
of Care).
VerDate Sep<11>2014
170.314(b)(1) (Transitions
of Care-Receive, Display
and Incorporate Transition
of Care/Referral Summaries) or
170.314(b)(8) (Optional
Transitions of Care).
170.314(b)(4) (Clinical Information Reconciliation)
or
170.314(b)(9) (Optional
Clinical Information Reconciliation and Incorporation).
N/A ......................................
170.314(f)(5) (Optional
Ambulatory Setting
OnlyCancer Case Information) and
170.314(f)(6) (Optional
Ambulatory Setting Only
Transmission to Cancer
Registries).
N/A ......................................
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Combinations
N/A.
170.315(b)(1) (Transitions
of Care).
N/A.
N/A.
N/A.
N/A.
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N/A.
N/A.
62882
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TABLE 14ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017
Objective
Measure(s)
Objective 1: Protect
Electronic Health Information.
Objective 2: Electronic
Prescribing.
VerDate Sep<11>2014
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Combinations
Eligible Hospitals/CAHs
may use a combination of technologies
certified to either the
2014 Edition or 2015
Edition.
170.314(a)(8) (Clinical
Decision Support).
170.315(a)(9) (Clinical
Decision Support).
N/A.
N/A.
N/A
N/A.
N/A.
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62883
TABLE 14ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017
Continued
Objective
Objective 5: Patient
Electronic Access.
Objective 6: ....................
Coordination of Care
through Patient Engagement.
VerDate Sep<11>2014
Measure(s)
2014 Edition
2015 Edition
Combinations
170.314(e)(1) (View,
Download, and Transmit to 3rd Party).
170.315(e)(1) (View,
Download, and Transmit to 3rd Party).
170.315(g)(7)* (Application AccessPatient Selection).
170.315(g)(8)* (Application AccessData
Category Request)*.
170.315(g)(9) (Application AccessAll Data
Request)*
* The three criteria combined are the API
certification criteria.
Eligible Hospitals/CAHs
may use technologies
certified to either the
2014 Edition or 2015
Edition VDT certification criteria (i.e.,
170.314(e)(1) or
170.315(e)(1))in
2017).
The 2014 Edition does
not offer API certification criteria.
Therefore, Eligible Hospitals/CAHs choosing
to attest to the Stage
3 measures in 2017
would need to possess technology certified to
170.315(g)(7),
170.315(g)(8), and
170.315(g)(9).
N/A.
170.314(e)(1) (View,
Download, and Transmit to 3rd Party).
170.315(e)(1) (View,
Download, and Transmit to 3rd Party).
170.315(g)(7) (Application AccessPatient
Selection)*.
170.315(g)(8) (Application AccessData
Category Request)*.
170.315(g)(9) (Application AccessAll Data
Request)*.
* The three criteria combined are the API
certification criteria.
170.314(e)(3) (Secure
Messaging).
170.315(e)(2) (Secure
Messaging).
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Eligible Hospitals/CAHs
may use technologies
certified to either the
2014 Edition or 2015
Edition VDT certification criteria (i.e.,
170.314(e)(1) or
170.315(e)(1)) in
2017.
The 2014 Edition does
not offer API certification criteria. Therefore, Eligible Hospitals/CAHs choosing
to attest to the Stage
3 measures in 2017
would need to possess technology certified to
170.315(g)(7),
170.315(g)(8), and
170.315(g)(9).
N/A.
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TABLE 14ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017
Continued
Objective
Objective 8: Public
Health and Clinical
Data Registry Reporting.
Measure(s)
2014 Edition
2015 Edition
N/A ................................
N/A.
170.315(e)(3) (Patient
Health Information
Capture)*..
*Supports meeting the
measure, but is NOT
required to be used to
meet the measure.
The certification criterion is part of the
CEHRT definition beginning in 2018.
170.315(b)(1) (Transitions of Care).
N/A.
170.314(b)(4) (Clinical
Information Reconciliation) or
170.314(b)(9) (OptionalClinical Information Reconciliation
and Incorporation).
N/A ................................
170.315(b)(2) (Clinical
Information Reconciliation and Incorporation).
N/A.
N/A.
N/A.
VerDate Sep<11>2014
N/A ................................
.......................................
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Combinations
N/A.
N/A.
N/A.
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62885
TABLE 14ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2017
Continued
Objective
Measure(s)
2014 Edition
2015 Edition
170.314(f)(4) (Inpatient
Setting OnlyTransmission of Reportable
Laboratory Tests and
Values/Results).
Combinations
N/A.
TABLE 15EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2018 AND SUBSEQUENT YEARS
Objective
Objective 1: Protect
Health Information.
Electronic
Measure(s)
2015 Edition
Measure 1: For more than 80% of all unique patients seen by the
EP:
(1) The patient (or the patient authorized representative) is provided
timely access to view online, download, and transmit his or her
health information; and
(2) The EP ensures the patients health information is available for
the patient (or patient-authorized representative) to access using
any application of their choice that is configured to meet the technical specifications of the API in the providers CEHRT.
Measure 2: The EP must use clinically relevant information from
CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35% of
unique patients seen by the EP.
Measure 1: For 2017, during the EHR reporting period, more than
10% of all unique patients(or patient-authorized representative)
seen by the EP actively engage with the EHR made accessible by
the provider. An EP may meet the measure by either
(1) view, download or transmit to a third party their health information; or
(2) access their health information through the use of an API that can
be used by applications chosen by the patient and configured to
the API in the providers CEHRT; or (3) a combination of (1) and
(2).
Measure 2: For 2017, more than 25% of all unique patients seen by
the EP during the EHR reporting period, a secure message was
sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a
secure message sent by the patient (or the patient-authorized representative.
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TABLE 15EP OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2018 AND SUBSEQUENT
YEARSContinued
Objective
Measure(s)
2015 Edition
170.315(b)(1)
Care).
(Transitions
of
TABLE 16ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2018 AND
SUBSEQUENT YEARS
Objective
Objective 1: Protect
Health Information.
Electronic
VerDate Sep<11>2014
Measure(s)
2015 Edition
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TABLE 16ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2018 AND
SUBSEQUENT YEARSContinued
Objective
Measure(s)
2015 Edition
Measure 2: More than 60% of laboratory orders created by the authorized providers of the eligible hospitals or CAHs inpatient or
emergency department (POS 21 or 23) during the EHR reporting
period are recorded using CPOE.
Measure 3: More than 60% of diagnostic imaging orders created by
the authorized providers of the eligible hospitals or CAHs inpatient
or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.
Measure 1: For more than 80% of all unique patients discharged
from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23):
(1) The patient (or the patient authorized representative) is provided
timely access to view online, download, and transmit his or her
health information.; and
(2) The provider ensures the patients health information is available
for the patient (or patient-authorized representative) to access
using any application of their choice that is configured to meet the
technical specifications of the API in the providers CEHRT.
Measure 2: The eligible hospital or CAH must use clinically relevant
information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more
than 35% of unique patients discharged from the eligible hospital
or CAH inpatient or emergency department (POS 21 or 23) during
the EHR reporting period.
Measure 1: During the EHR reporting period, more than 10 percent
of all unique patients (or their authorized representatives) discharged from the eligible hospital or CAH inpatient or emergency
department (POS 21 or 23) actively engage with the EHR made
accessible by the provider and either:
(1) view, download or transmit to a third party their health information; or
(2) access their health information through the use of an API that can
be used by applications chosen by the patient and configured to
the API in the providers CEHRT; or
(3) a combination of (1) and (2) ............................................................
Measure 2: For more than 25% of all unique patients discharged
from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period, a secure
message was sent using the electronic messaging function of
CEHRT to the patient (or the patient-authorized representative), or
in response to a secure message sent by the patient (or the patient-authorized representative) during the EHR reporting period.
Measure 3: Patient-generated health data or data from a non-clinical
setting is incorporated into the CEHRT for more than 5% of all
unique patients discharged from the eligible hospital or CAH (POS
21 and 23) during the EHR reporting period.
170.315(a)(2) (Computerized
Provider Order EntryLaboratory).
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170.315(a)(3)
(Computerized
Provider Order EntryDiagnostic Imaging).
170.315(e)(1) (View, Download,
and Transmit to 3rd Party)
170.315(g)(7)* (Application AccessPatient Selection).
170.315(g)(8)* (Application AccessData Category Request)*.
170.315(g)(9) (Application AccessAll Data Request)*
*The three criteria combined are
the API certification criteria.
170.315(a)(13) (Patient-Specific
Education Resources).
170.315(b)(1)
Care).
(Transitions
of
16OCR3
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TABLE 16ELIGIBLE HOSPITAL/CAH OBJECTIVES, MEASURES, AND CERTIFICATION CRITERIA FOR STAGE 3 IN 2018 AND
SUBSEQUENT YEARSContinued
Objective
Measure(s)
2015 Edition
170.315(f)(5) (Transmission to
Public Health AgenciesElectronic Case Reporting).
Eligible
Hospitals/CAHs
may
choose one or more of the following:
170.315(f)(6) (Transmission to
Public Health AgenciesAntimicrobial Use and Resistance).
170.315(f)(7) (Transmission to
Public Health AgenciesHealth
Care Surveys).
No 2015 Edition health IT certification criteria at this time.
170.315(f)(3) (Transmission to
Public Health AgenciesReportable Laboratory Tests and
Values/Results).
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the 2014 electronic specifications for the
CQMs (which are also known as
eCQMs) for a reporting period in 2015.
We also noted that eligible hospitals and
CAHs seeking to participate in multiple
programs with a single electronic
submission for a reporting period in
2015 would be required to submit one
calendar quarter of data for 2015 from
either Q1 (January 1, 2015March 31,
2015), Q2 (April 1, 2015June 30, 2015),
or Q3 (July 1, 2015September 30, 2015)
and would require of the use of the
April 2014 release of the eCQMs. For
further information on the requirements
for eligible hospitals and CAHs
electronically submitting CQMs for a
reporting period in 2015 for the
Medicare EHR Incentive Program, we
referred readers to the FY 2015 IPPS
final rule (79 FR 50319 through 50323).
We noted that an EHR certified for
CQMs under the 2014 Edition
certification criteria does not need to be
recertified each time it is updated to a
more recent version of the eCQMs.
Comment: We received many
comments in support of maintaining the
existing CQM reporting requirements
and aligning CQM requirements with
other quality programs where possible,
including support of our proposal to
align reporting for eligible hospitals and
CAHs to the calendar year. Some
commenters expressed concerns over
their ability to report CQMs, and some
commenters requested that CMS expand
the number of CQMs available to
specialists.
Response: We appreciate the
comments in support of our proposals
and understand the concerns raised by
others. CMS continues to evaluate the
available CQMs for inclusion in the EHR
Incentive Programs and will consider
adding CQMs to the program as they are
developed and found to be appropriate
for inclusion. In the meantime, we
understand that there are situations in
which an EP, eligible hospital or CAH
does not have data to report on for a
particular CQM, and its EHR is not
certified to additional CQMs or does not
have additional CQMs available to
report on. In these instances, we believe
that our policy on allowing zero
denominators to be reported allow these
providers and specialists to meet the
CQM reporting requirements of the EHR
Incentive Programs (see the Stage 2 final
rule 77 FR 54059 and 54079 and FY
2015 IPPS final rule 79 FR 50323).
Comment: A few commenters
suggested that we further align the
Medicare EHR Incentive Program with
PQRS and allow EPs reporting through
a Qualified Clinical Data Registry
(QCDR) to satisfy the CQM reporting
requirements for meaningful use.
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to ensure that CQMs used in quality
reporting programs are updated
regularly.
Comment: Some commenters
expressed concerns regarding the
amount of time between the publication
of the IPPS final rule and when the
CQMs and policies would go into effect.
Many expressed concern over whether
their EHR vendor would have time to
certify and update their system to the
most recent version of the CQMs, and a
few went on to request that changes to
CQMs and submission requirements not
change from one quarter reporting
period to the next.
Response: We understand the
commenters concerns and note that
CQMs referenced in the IPPS
rulemaking are generally updated
annually, and certain updates are posted
in advance of the final rule. The 2016
IPPS final rule provides flexibility to
eligible hospitals and CAHs needing to
update their EHR systems only for the
most recent version of the CQMs. No
changes to 2014 CEHRT criteria or
timelines are being finalized in this final
rule with comment period.
Comment: Some commenters
expressed concerns related to CMS
ability to accept electronically
submitted CQMs.
Response: We understand the
commenters concerns. CMS has worked
to continually develop and improve its
CQM receiving system for the purposes
of collecting CQMs electronically.
Comment: Some commenters noted
that the Hospital IQR Program is not
required for CAHs and requested
clarification on how the alignment of
the Medicare EHR Incentive Program
and Hospital IQR Program would
impact CAHs seeking to electronically
submit their CQM data.
Response: We agree that the Hospital
IQR Program is not required for CAHs.
Only subsection (d) hospitals are subject
to the requirements and payment
reductions of the Hospital IQR Program.
For the EHR Incentive Programs, CAHs
may continue to report their CQM data
by attestation in CY 2016. However, we
encourage CAHs to submit their CQMs
electronically through the QualityNet
portal. We believe electronic submission
of CQMs is an important next step in the
meaningful use of certified EHR
technology, and encourage CAHs to
begin submitting CQMs electronically in
2016. We further note that in section
II.C.4 of this final rule with comment
period, we finalize our policy to require
the electronic submission of CQMs
starting in 2018 and thus encourage
CAHs to begin electronically reporting
CQMs as soon as feasible.
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participating for the first time in 2017 to
use a 90-day reporting period for CQMs.
After consideration of the public
comments that we received, we are
finalizing our proposal to require a
reporting period of one full calendar
year which consists of 4 quarterly data
reporting periods starting in 2017 for
eligible hospitals and CAHs
participating in the Medicare and
Medicaid EHR Incentive Program. We
are finalizing with modification our
proposal of a limited exception for
eligible hospitals and CAHs
demonstrating meaningful use for the
first time under the Medicaid EHR
Incentive Program. For these eligible
hospitals and CAHs, the reporting
period for CQMs would be any
continuous 90-day period within the
CY, with the modification that it could
be a different 90-day period than their
EHR reporting period for the incentive
payment under Medicaid. More details
of the form and manner will be
provided in the IPPS rulemaking cycle.
c. Reporting Flexibility for EPs, Eligible
Hospitals, and CAHs in 2017
We proposed that EPs, eligible
hospitals, and CAHs would be able to
have more flexibility to report CQMs in
one of two ways in 2017via electronic
reporting or attestation (80 FR 16770).
First EPs, eligible hospitals, and CAHs
may choose to report eCQMs
electronically using the CQMs finalized
for use in 2017 using the most recent
version of the eCQMs (electronic
specifications), which would be the
electronic specifications of the CQMs
published by CMS in 2016. Alternately,
a provider may choose to continue to
62893
TABLE 17PROPOSED ECQM REPORTING TIMELINES FOR MEDICARE AND MEDICAID EHR INCENTIVE PROGRAM
Year
2017 Only
2017 Only
Attestation .........................
All Medicare providers ......
Medicaid providers must
refer to state requirements for reporting.
Electronic Reporting
All Medicare Providers
Medicaid providers must
refer to state requirements for reporting.
Attestation .........................
Medicare Providers with
circumstances rendering
them unable to eReport.
Medicaid providers must
refer to state requirements for reporting.
1 CY for Medicare .............
1 CY for returning Medicaid.
90 days for first time
meaningful user Medicaid.
2016 Annual Update or
more recent version.
2015 Edition
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1 CY for returning Medicaid
90 days for first time
meaningful user Medicaid.
2017 Annual Update.
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requiring attestation within the 2
months after the close of the fiscal year
for returning eligible hospitals and
CAHs or calendar year for returning EPs.
We further note that this attestation
period also aligns with the submission
period for CQM reporting for PQRS. We
understand the concern over a high
volume of attestations. However, as
noted previously, we do not anticipate
that the proposed changes to the
attestation deadlines would
significantly increase the volume over
what was expected for 2015. In
addition, as we have done in past years,
we will monitor progress, attestation
volume, and provider readiness in real
time as the attestation period progresses.
Comment: A commenter requested
that we clarify how the requirements of
the program prior to the final rule relate
to those after the effective date of the
final rule in terms of the attestation
windows and selection of an EHR
reporting period. The commenter
requested that new participants be able
to attest to the current Stage 1 objectives
and measures even after the effective
date of this final rule with comment
period for an EHR reporting period in
2015. The commenter also requested
guidance on whether states will be
required to take an approach consistent
with CMS on this issue.
Response: Any attestations accepted
by a state for the Medicaid EHR
Incentive Program prior to the effective
date of this final rule with comment
period must meet the requirements in
effect at that time for the Medicaid EHR
Incentive Program. In addition, the
objectives and measures of meaningful
use apply to both the Medicare and
Medicaid EHR Incentive Programs, and
the demonstration methods we adopt for
Medicare would automatically be
available to the states for use in their
Medicaid programs.
We refer the commenter to sections
II.B.1.b.(4).(a). and II.E. of this final rule
with comment period for an explanation
of when in 2015 the 90-day EHR
reporting period and EHR reporting
period for a payment adjustment year
may occur. We further note that CMS
will not be accepting attestations for an
EHR reporting period in 2015 and
subsequent years for any objective or
measure which has been removed in
this final rule with comment period in
section II.B.1.b.(4).(b).
Comment: A commenter stated that
providers believe that the management
of attestation deadlines and payment
adjustments is very complicated and
difficult to follow.
Response: We note that this is part of
the motive behind some of the changes
to reporting periods for the Medicare
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comment period, EHR technology
certified to the 2015 Edition can support
the Stage 2 objectives and measures, but
EHR technology certified to the 2014
Edition on its own cannot support all of
the Stage 3 objectives and measures. So
even though EHR technology certified to
the 2015 Edition is not required until
2018, a provider must at least have the
functions of CEHRT certified to the 2015
Edition which are required to support
the unique Stage 3 measures in order to
participate in Stage 3 in 2017. For Stage
3 there are certain EHR technology
functions which are not available within
the 2014 Edition certification criteria,
and if a provider chooses to attest to
Stage 3 in 2017 they must use EHR
technology modules certified to the
2015 Edition for those functions. These
modules and module certified to the
2014 Edition can be used together in
many combinations to make up the
whole EHR system and meet the
definition of CEHRT required for the
program. We direct readers to section
II.B.3. of this final rule with comment
period for further information on the
CEHRT definition at 495.4. See Tables
14, 15, and 16 in section II.B.3. for more
information about which modules
support specific Stage 3 objectives and
measures.
We believe providing flexibility in
2017 will allow for an easier transition
and full scale upgrade to EHR
technology certified to the 2015 Edition
for participation in 2018. We did not
propose an extension of this flexibility
into 2018 as we are committed to
moving toward a single streamlined
program to support long term
sustainability and reduce the overall
complexity for providers participating
in the EHR Incentive Programs. We note
that, as mentioned in section II.B.1.b.(3).
of this final rule with comment period,
we are finalizing a 90-day EHR reporting
period for providers demonstrating
Stage 3 in 2017 to further support
providers seeking to move to Stage 3 in
2017.
After consideration of the comments
received, we are finalizing a
modification to our proposal to allow
providers using EHR technology
certified to the 2015 Edition, in whole
or in part, the option to attest to Stage
3 objectives and measures if they have
the relevant CEHRT modules certified to
the 2015 Edition certification criteria
necessary to support Stage 3. (See
Tables 14, 15, 16 in section II.B.3. for
more information about which modules
support specific Stage 3 objectives and
measures.) We further note that CMS
will not be accepting attestations for an
EHR reporting period in 2015 and
subsequent years for any objective or
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comments both in support of and
opposing a revision to the hospitalbased EP definition show the wide
diversity of providers who may have
services billed under a different POS
who fall on both sides of the argument
for and against an amendment of the
definition. We see no method to modify
the current definition to clearly identify
EPs for whom inclusion in the
definition might be reasonable and
those for whom inclusion in the
definition might be inappropriate.
Further, we are concerned that any
blanket redesignation of EPs in certain
settings would result in the exclusion of
patient encounters in those settings
being captured in an EHR. Without a
clear rationale for a change, and without
a clear definition to change to, we
cannot proceed to change the definition
of hospital-based EP at this time.
Therefore, we are not finalizing
changes to the definition of hospitalbased EP at this time. We will continue
to consider this issue in the future as we
explore program requirements for the
MIPS.
5. Interaction With Other Programs
We proposed no changes to the ability
of providers to participate in the
Medicare and Medicaid EHR Incentive
Programs and other CMS programs. We
continue to work on aligning the data
collection and reporting of the various
CMS programs, especially in the area of
clinical quality measurement. See
sections II.C. of this final rule with
comment period for the policies and
requirements for CQM reporting.
E. Payment Adjustments and Hardship
Exceptions
Sections 4101(b) and 4102(b) of the
HITECH Act, amending sections 1848,
1853, and 1886 of the Act, require
reductions in payments to EPs, eligible
hospitals, and CAHs that are not
meaningful users of certified EHR
technology, beginning in CY 2015 for
EPs, FY 2015 for eligible hospitals, and
in cost EHR reporting periods beginning
in FY 2015 for CAHs.
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TABLE 18EHR REPORTING PERIODS AND RELATED PAYMENT ADJUSTMENT YEARS FOR EPS
2015
EHR reporting period for a
payment adjustment year
No .................................................
2016
2017
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We disagree that the change to a fullyear EHR reporting period unfairly
impacts new participant. We note that
the prior exception to allow a 90-day
EHR reporting period favors new
participants over returning participants
who have no such opportunity to avoid
a payment adjustment in the subsequent
year. We further note that new
participants could have chosen to begin
the program at any time since 2011
unless they are newly practicing
providers who are already afforded a
hardship exception from the penalty.
After consideration of the public
comments, we are finalizing the
following changes to the EHR reporting
period for a payment adjustment year
for eligible hospitals as proposed, with
a modification for the EHR reporting
period in 2017. For the reasons stated in
section II.E.2.a. of this final rule with
comment period for Medicaid EPs
participating in Stage 3 in 2017, we are
finalizing a similar policy for eligible
hospitals to establish a 90-day EHR
reporting for Stage 3 participants in
2017 for the purposes of avoiding the
payment adjustment in 2019 for
returning participants and for the
payment adjustment in 2018 for new
participants who attest to Stage 3 prior
to October 1, 2017. For further
discussion of the policy related to the
EHR reporting period in 2017 we direct
readers to section II.B.1.b.(3).iii. of this
final rule with comment period.
In CY 2015, the EHR reporting period
for a payment adjustment year for
eligible hospitals that have not
successfully demonstrated meaningful
use in a prior year (new participants) is
any continuous 90-day period beginning
on October 1, 2014 and ending on
December 31, 2015. An eligible hospital
that successfully demonstrates
meaningful use for this period and
satisfies all other program requirements
will avoid the payment adjustment in
FYs 2016 and 2017 if the eligible
hospital successfully attests by February
29, 2016.
In CY 2015, the EHR reporting period
for a payment adjustment year for
eligible hospitals that have successfully
demonstrated meaningful use in a prior
year (returning participants) is any
continuous 90-day period beginning on
October 1, 2014 and ending on
December 31, 2015. An eligible hospital
that successfully demonstrates
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TABLE 19EHR REPORTING PERIODS AND RELATED PAYMENT ADJUSTMENT YEARS FOR ELIGIBLE HOSPITALS
2015
No .................................................
2016
EHR reporting period for a
payment adjustment year
CY 2016 ........................................
No .................................................
Yes, if eligible
fully attests
2017.
Yes, if eligible
fully attests
2017.
2017
EHR reporting period for a
payment adjustment year
CY 2017 ........................................
No .................................................
Yes, if eligible
fully attests
2018.
Yes, if eligible
fully attests
2018.
Yes, if eligible
fully attests
2018.
2018
EHR reporting period for a
payment adjustment year
CY 2018 ........................................
No .................................................
No .................................................
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Yes, if eligible
fully attests
2019.
Yes, if eligible
fully attests
2019.
Yes, if eligible
fully attests
2019.
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TABLE 20EHR REPORTING PERIODS AND RELATED PAYMENT ADJUSTMENT YEARS FOR CAHS
2015
CY 2016.
2017
EHR reporting period for a payment
adjustment year
CAH new participants ........................................
2018
EHR reporting period for a payment
adjustment year
CAH new participants ........................................
CY 2018.
3. Hardship Exceptions
As stated previously, sections
1848(a)(7)(B) and 1886(b)(3)(B)(ix)(II) of
the Act provide the Secretary with
discretionary authority to exempt, on a
case by case basis, a provider from the
application of the Medicare payment
adjustment if the Secretary determines
that compliance with the requirements
for being a meaningful EHR user would
result in a significant hardship. We have
established various types of hardship
exceptions for which providers may
apply as well as deadlines for
application. For more information, we
refer readers to the Stage 2 final rule at
77 FR 54093 through 54113.
In the EHR Incentive Programs in
2015 through 2017 proposed rule (80 FR
20381), we proposed no changes to the
types of hardship exceptions available
to EPs, eligible hospitals, and CAHs.
Further, we proposed no changes to the
existing hardship exception process and
timelines under our regulations.
In the Stage 3 proposed rule we
proposed no changes to the types of
exceptions previously finalized for EPs,
eligible hospitals or CAHs (80 FR 16775,
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new hardship exception categories for
the EHR Incentive Programs.
Commenters believed that there should
be additional exception categories,
especially for providers experiencing
issues with certified EHR technology
and EHR vendors; providers who are
unable to achieve meaningful use due to
the all-or-nothing approach; providers
practicing in multiple locations or who
have transitioned between locations;
providers who are beyond retirement
age; specialty providers; providers who
are new to the EHR Incentive Program
and have not yet achieved meaningful
use; providers who see observation
patients; and fellows. Commenters
believe providers who fall into any of
these categories have significant reasons
to be included in the list of those who
qualify for hardship exceptions and
should not receive payment
adjustments.
Response: We note that providers may
already apply for a hardship exception
under the extreme and uncontrollable
circumstances category if they
experience issues with a vendor product
including issues related to upgrades and
transitions from one product to another.
In addition, we note that new
participants have the same ability to
apply for a hardship exception as any
other provider. We also established
hardship exception categories for newly
practicing EPs, new eligible hospitals,
and new CAHs. We do not believe there
are acceptable standards to establish a
category based on age or potential
retirement status given the wide
variation among providers and potential
influencing factors. Finally, we believe
that the existing categories are broad
and comprehensive enough to cover
many different circumstances where
meeting the program requirements
would be a significant hardship due to
circumstances outside the control of the
provider and related to their particular
practice or organization.
Comment: Some commenters
requested clarification around whether
the 5-year limitation for hardship
exceptions will be applicable to
providers with PECOS specialties of
diagnostic radiology (30), nuclear
medicine (36), interventional radiology
(94), anesthesiology (05), and pathology
(22). Commenters believed these
providers might retain the same PECOS
specialty code for more than 5 years.
Response: Under section 1848(a)(7)(B)
of the Act, the Secretary has discretion,
on a case-by-case basis, to exempt an EP
from the Medicare payment adjustment
if the Secretary determines, subject to
annual renewal, that requiring the EP to
be a meaningful EHR user would result
in a significant hardship. Such
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the federal fiscal year in which the final
rule takes effect.
Comment: Commenters supported our
proposal to remove practice location
from the annual report. A commenter
noted that their state already reports
practice location, but does not find this
data point to be beneficial and is in
favor of removing this requirement.
Another commenter finds this
requirement to be burdensome because
it requires manual review of attestations
in order to identify accurate data on
practice locations, and fears this will
lead to inaccurate data.
Response: We appreciate the
commenters feedback on this topic.
While we believe that there is a benefit
to having states report this information
in the annual reports, we believe that
this benefit is outweighed by the burden
of states having to collect and report this
information on providers. Moreover,
there is also a risk that inaccurate
practice location data may be reported
due to manual data collection processes.
We believe that we can effectively
oversee the program without states
reporting this particular information.
Therefore, we intend to remove the
requirement at 495.316(d)(1)(i) and
(iii) that states report information about
practice location for providers that
qualify for incentive payments on the
basis of having adopted, implemented,
or upgraded CEHRT or on the basis of
demonstrating they are meaningful
users of CEHRT. We encourage states to
collect and use practice location
information, as it could prove useful
and may differ from the business
address information that is used for
program administration purposes.
Comment: Commenters supported the
proposed requirement for states to
submit quarterly progress reports to
CMS within 30 days after the end of
each federal fiscal year quarter and do
not anticipate that this requirement
would create any burden.
Response: Based on the positive
feedback we are finalizing the proposal
with a modification to require the
deadline of 30 days after the end of each
federal fiscal year quarter that was
discussed in the proposed rule. In order
to give states sufficient time to prepare
to submit the quarterly reports, the first
report under the amendments to
495.352 will be due in the second
quarter following the one in which the
final rule takes effect.
Comment: A commenter
recommended that all public health
measures collected or tracked through
the state reporting activities be reported
to the public health agency.
Response: We support the notion of
sharing public health measures
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ObjectivesEligible
hospitals/CAHs
Measures
6 hours ..........................
6 hours.
10 minutes ....................
10 minutes.
1 minute ........................
1 minute.
10 minutes ....................
10 minutes.
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ObjectivesEligible
hospitals/CAHs
Measures
10 minutes ....................
10 minutes.
10 minutes ....................
10 minutes.
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TABLE 21BURDEN ESTIMATES STAGE 3 495.24Continued
ObjectivesEligible
professionals
ObjectivesEligible
hospitals/CAHs
.......................................
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Measures
Measure 3: Patient-generated health
data or data from a non-clinical
setting is incorporated into the
CEHRT for more than 5 percent of
all unique patients seen by the EP
or discharged by the eligible hospital or CAH (POS 21 or 23) during the EHR reporting period.
Measure 1: For more than 50 percent of transitions of care and referrals, the EP, eligible hospital or
CAH that transitions or refers their
patient to another setting of care
or provider of care(1) creates a
summary of care record using
CEHRT; and (2) electronically exchanges the summary of care
record.
Measure 2: For more than 40 percent of transitions or referrals received and patient encounters in
which the provider has never before encountered the patient, the
EP, eligible hospital or CAH incorporates into the patients record
an electronic summary of care
document from a source other
than the providers EHR system.
Measure 3: For more than 80 percent of transitions or referrals received and patient encounters in
which the provider has never before encountered the patient, the
EP, eligible hospital, or CAH performs a clinical information reconciliation. The provider must implement clinical information reconciliation for the following three
clinical information sets:
Medication. Review of the patients
medication, including the name,
dosage, frequency, and route of
each medication.
Medication allergy. Review of the
patients known medication allergies.
Current Problem list. Review of the
patients current and active diagnoses.
Measure 1Immunization Registry
Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency
to submit immunization data and
receive immunization forecasts
and histories from the public
health immunization registry/immunization information system
(IIS).
Measure 2Syndromic Surveillance
Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency
to submit syndromic surveillance
data from an urgent care setting
(urgent care ambulatory for EP,
emergency or urgent care department for eligible hospitals and
CAHs).
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10 minutes ....................
10 minutes.
1 minute ........................
1 minute.
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hospitals/CAHs
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Measures
Measure 3Electronic Case Reporting: The EP, eligible hospital, or
CAH is in active engagement with
a public health agency to submit
case reporting of reportable conditions.
Measure 4Public Health Registry
Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency
to submit data to public health
registries.
Measure 5Clinical Data Registry
Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical
data registry.
EPs must meet 2 measures and
may choose to report to more
than one public health registry or
clinical data registry to meet the
objective.
Measure 1Immunization Registry
Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency
to submit immunization data and
receive immunization forecasts
and histories from the public
health immunization registry/immunization information system
(IIS).
Measure 2Syndromic Surveillance
Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency
to submit syndromic surveillance
data from an urgent care setting
(urgent care ambulatory for EP,
emergency or urgent care department for eligible hospitals and
CAHs).
Measure 3Electronic Case Reporting: The EP, eligible hospital, or
CAH is in active engagement with
a public health agency to submit
case reporting of reportable conditions.
Measure 4Public Health Registry
Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency
to submit data to public health
registries.
Measure 5Clinical Data Registry
Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical
data registry.
Measure 6Electronic Reportable
Laboratory Result Reporting: The
eligible hospital or CAH is in active engagement with a public
health agency to submit ELR results.
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TABLE 21BURDEN ESTIMATES STAGE 3 495.24Continued
ObjectivesEligible
professionals
ObjectivesEligible
hospitals/CAHs
Measures
.......................................
6 hours 52 minutes
.......................................
...........................................................
6 hours 52 minutes
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required to prepare for attestation. They
also stated that CMS should more
carefully consider the multiple factors
that contribute to the burden of
physician reporting.
Response: We appreciate the public
comments on this burden analysis.
However, this analysis specifically
reflects the amount of time we estimate
providers will take to prepare and report
their meaningful use data through the
Medicare and Medicaid EHR Incentive
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Measures
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6 hours ..........................
6 hours.
1 minute ........................
1 minute.
10 minutes ....................
10 minutes.
10 minutes
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TABLE 22BURDEN ESTIMATES 495.22Continued
Eligible professionals
Measures
10 minutes ....................
10 minutes.
.......................................
10 minutes.
10 minutes ....................
10 minutes.
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.......................................
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TABLE 22BURDEN ESTIMATES 495.22Continued
Eligible professionals
Measures
.......................................
1 minute ........................
1 minute.
.......................................
6 hours 48 minutes.
.......................................
...........................................................
1 hour 30 minutes.
.......................................
...........................................................
8 hours 18 minutes.
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BLS data)). Similarly, eligible hospitals
and CAHs will attest that they have met
the meaningful use objectives and
associated measures, and would submit
the clinical quality measures. We
estimate that it will take no longer than
6 hours 48 minutes to attest to each of
the applicable objectives and associated
measures. Therefore, the total burden
hours for an eligible hospital or CAH to
attest to the meaningful use objectives
and measures and to report CQMs, will
be 8 hours 18 minutes. We estimate that
there are about 4,900 eligible hospitals
and CAHs that may attest to the
aforementioned criteria in FY 2015 of
which 95 percent are expected to
demonstrate meaningful use. The total
NA.
10 hours 55 minutes.
8 hours 18 minutes.
NA.
2 hour 37 minutes.
Burden reduction
hours
Hourly cost
Reduction per
respondent
387,060 ................................................................
387,060 ................................................................
4,655 ....................................................................
Total Least ...........................................................
Total Most ............................................................
1.45
1.9
2.62
..............................
..............................
$92.25
92.25
63.46
..............................
..............................
$133.76
175.28
166.27
..............................
..............................
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495.xObjectives/
Measures (EPs) ........
495.6Objectives/
Measures (hospitals/
CAHs) .......................
495.210Gather information for attestation (MA EPs) ...........
495.210Attestation
on behalf of MA EPs
495.316Quarterly
Reporting ..................
Totals ....................
OMB control
No.
Number of
respondents
Burden per
response
(hours)
Number of
responses
Total annual
burden
(hours)
Hourly labor
cost of
reporting
($)
Total cost
($)
09381158
609,100
609,100
6.86
4,178,426
92.25
385,834,395
09381158
4,900
4,900
6.86
33,614
63.46
2,135,204
09381158
13,635
13,635
0.75
10,226
25.00
255,650
09381158
13,635
13,635
0.25
3408.75
50.00
170,400
09381158
56
224
20
4480
3.00
13,440
........................
627,635
627,635
........................
4,225,674
........................
388,408,189
Notes: 1. All non-whole numbers in this table are rounded to 2 decimal places.
2. There are no capital/maintenance costs associated with the information collection requirements contained in this rule. Therefore, we removed the associated column from Table 22.
B. Overall Impact
A. Statement of Need
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The portion of the final rule related to
Stage 3 is one of two coordinated rules
related to the EHR Incentive Programs.
The other is ONCs 2015 Edition Health
Information Technology (Health IT)
Certification Criteria, 2015 Edition Base
Electronic Health Record (EHR)
Definition, and ONC Health IT
Certification Program Modifications.
Thus, there is an analysis that focuses
on the impact associated with Stage 3
requirements for the EHR Incentive
Program, the changes in quality
measures that would take effect
beginning in 2017, and other changes
being for the Medicare and Medicaid
EHR Incentive Programs.
As we discussed in the Stage 2 final
rule (77 FR 54163 through 54291), a
number of factors would affect the
adoption of EHR systems and
demonstration of meaningful use. In this
final rule with comment period, we
continue to believe that a number of
factors would affect the adoption of EHR
systems and demonstration of
meaningful use. Readers should
understand that these forecasts are also
subject to substantial uncertainty since
meeting the requirements of the
program will depend not only on the
standards and requirements for 2017
and for eligible hospitals and EPs, but
on future rules issued by the
Department of Health and Human
Services (DHHS).
Based on the Stage 2 final rule, we
expect spending under the EHR
Incentive Programs for transfer
payments to Medicare and Medicaid
providers between 2015 and 2017 to be
$14.2 billion. However, the policies in
this final rule with comment period
which are applicable for the EHR
Incentive Programs in 2015 through
2017 do not change these estimates over
the current period as the proposals in
the EHR Incentive Programs in 2015
through 2017 proposed rule applied no
changes to the payment of incentives or
the application of payment adjustments
for 2015 through 2017.
Our analysis of impacts for the
policies in this final rule with comment
period relate to the reduction in cost
associated with provider reporting
burden estimates for 2015 through 2017
as affected by the adopted changes to
the current program and to the transfer
payments for incentives for Medicaid
providers and reductions in payments
for Medicare providers through payment
adjustments for 2018 and subsequent
years. In the Stage 3 proposed rule, we
noted our expectation that spending
under the EHR Incentive Program for
transfer payments to Medicare and
Medicaid providers between 2017 and
2020 to be $3.7 billion (this estimate
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TABLE 26MEDICARE EPS DEMONSTRATING MEANINGFUL USE OF CEHRT
Calendar Year
2015
Medicare EPs who have claims with Medicare (in thousands) ......................................
Nonhospital-based Medicare EPs (in thousands) ...........................................................
Percent of EPs who are Meaningful Users .....................................................................
Meaningful Users (in thousands) .....................................................................................
2016
660.0
595.1
60
357.1
2017
667.8
602.1
65
391.4
675.5
609.1
70
426.4
2016
357.1
$47,760,345.60
$62,585,476.80
2017
391.4
$52,353,664.00
$68,604,592.00
426.4
$57,035,264.00
$74,739,392.00
TABLE 28MEDICARE ELIGIBLE HOSPITALS AND CAHS DEMONSTRATING MEANINGFUL USE OF CEHRT
Calendar Year
2015
Eligible Hospitals .............................................................................................................
CAHs ................................................................................................................................
Percent Demonstrating Meaningful Use ..........................................................................
Meaningful Users .............................................................................................................
2016
3397
1395
95
4552
2017
3397
1395
97
4648
3397
1395
99
4744
TABLE 29ESTIMATED COST REDUCTION FOR MEDICARE ELIGIBLE HOSPITALS AND CAHS
Calendar Year
2015
Meaningful Users .............................................................................................................
Estimated Cost Savings ..................................................................................................
2016
4552
$756,861.04
2017
4648
$772,822.96
4744
$788,784.88
2015
Medicaid only EPs ...........................................................................................................
Percent of EPs who are Meaningful Users .....................................................................
Meaningful Users (in thousands) .....................................................................................
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58.3
51
30
E:\FR\FM\16OCR3.SGM
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59.4
53
31.48
16OCR3
60.6
55
33.33
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TABLE 31ESTIMATED COST REDUCTION FOR MEDICAID ONLY EPS
Calendar Year
2015
2016
30,000
$4,012,800.00
$5,258,400.00
2017
31,480
$4,210,764.80
$5,517,814.40
33,330
$4,458,220.80
$5,842,082.40
2016
108
95
103
2017
108
97
105
108
99
107
TABLE 33ESTIMATED COST REDUCTION FOR MEDICARE ELIGIBLE HOSPITALS AND CAHS
Calendar year
(2) Stage 3
In the Stage 2 final rule (77 FR 54136
through 54146), we estimated the
impact on healthcare providers using
information from four studies. In the
absence of any more recent estimates
that we are aware of, in this final rule
with comment period, we continue to
use the same estimates cited in the Stage
2 final rule. We continue to believe that
these estimates are reasonably reflective
of EHR costs. However, we note, we are
unable to delineate all costs due to the
great variability in characteristics among
the entities that are affected by the final
rule; the variability includes, but is not
limited to, the size of the practice,
extent of use of electronic systems, type
of system used, number of staff using
the EHR system and the cost for
maintaining and upgrading systems or
both. Based on these studies and current
average costs for available CEHRT
products, we continue to estimate for
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2015
2016
2017
4552
$17,125.81
4648
$17,458.35
4744
$17,790.89
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c. Costs of EHR Adoption for EPs
Since the publication of the Stage 1
final rule, there has been little data
published regarding the cost of EHR
adoption and implementation. A 2011
study (http://content.healthaffairs.org/
content/30/3/481.abstract) estimated
costs of implementation for a fivephysician practice to be $162,000, with
$85,500 in maintenance expenses in the
first year. In the absence of additional
data regarding the cost of adoption and
implementation costs for certified EHR
technology, we proposed to continue to
estimate for EPs that the average adopt/
implement/upgrade cost is $54,000 per
physician FTE, while annual
maintenance costs average $10,000 per
physician FTE, based on the cost
estimate of the Stage 1 final rule.
However, as noted previously, we are
unable to delineate all costs due to the
great variability that are affected by but
not limited to the size of the practice,
extent of use of electronic systems, type
of system used, number of staff using
the EHR system, and the cost for
maintaining and upgrading systems or
both.
d. Costs of EHR Adoption for Eligible
Hospitals
According to the American Hospital
Association 2008 Survey, the range in
yearly information technology spending
among hospitals ranged from $36,000 to
over $32 million. EHR system costs
specifically were reported by other
experts to run as high as $20 million to
$100 million (77 FR 54139). We note
that recently about 96 percent of eligible
hospitals have received at least one
incentive payment under either the
62935
About 16 MA organizations
a. Medicare Program Costs for Stage 3
The estimates for the HITECH Act
provisions are based on the economic
assumptions underlying the Presidents
FY 2016 Budget. Under the statute,
Medicare incentive payments for
CEHRT are excluded from the
determination of MA capitation
benchmarks. We continue to expect a
negligible impact on benefit payments
to hospitals and EPs from Medicare and
Medicaid because of the
implementation of EHR technology.
As noted at the beginning of this
analysis, it is difficult to predict the
actual impacts of the HITECH Act with
great certainty. We believe the
assumptions and methods described
herein are reasonable for estimating the
financial impact of the provisions on the
Medicare and Medicaid programs, but
acknowledge the wide range of possible
outcomes.
(1) Medicare Eligible Professionals (EPs)
We began making EHR Incentive
payments in 2011. Medicare payments
are to be paid for the successful
demonstration on meaningful use
through CY 2016. Due to the payment
lag, some payments may be issued in CY
2017. To avoid the Medicare payment
adjustment beginning in 2015, EPs need
to successfully demonstrate meaningful
use regardless of whether they earn an
incentive payment. We estimated the
percentage of the remaining EPs who
would be meaningful users each
calendar year. Table 34 shows the
results of these calculations.
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2018
675.5
609.1
70
426.4
683.3
616.1
73
446.7
2019
691.1
623.1
75
467.3
2020
698.8
630.1
78
488.3
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TABLE 35ESTIMATED COSTS (+) AND SAVINGS () FOR MEDICARE EPS DEMONSTRATING MEANINGFUL USE OF CEHRT
[in billions]
Incentive
payments
Fiscal year
2017
2018
2019
2020
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
Payment
adjustment
receipts
$0.2
0.2
0.2
0.1
$0.6
........................
........................
........................
Benefit
payments
Net total
........................
........................
........................
........................
$0.3
0.2
0.2
0.1
TABLE 36ESTIMATED COSTS (+) AND SAVINGS () FOR MEDICARE ELIGIBLE HOSPITALS DEMONSTRATING MEANINGFUL
USE OF CEHRT
[in billions]
Incentive
payments
Fiscal year
2017
2018
2019
2020
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
1 Savings
(1)
(1)
0.0
0.0
$1.6
0.0
0.0
0.0
Benefit
payments
Net total
(1 )
(1 )
(1)
(1)
$1.6
(1 )
( 1)
( 1)
Payment
adjustment
receipts
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62937
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
1 Savings
Eligible
professionals
0.4
0.1
0
0.0
Benefit
payments
Net total
(1)
(1)
(1)
(1)
0.8
0.5
0.3
0.2
1.2
0.6
0.3
0.2
TABLE 38ASSUMED NUMBER OF NONHOSPITAL BASED MEDICAID EPS WHO WOULD BE MEANINGFUL USERS OF
CEHRT
[Population figures in thousands]
Calendar year
2017
A ..................
B ..................
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2018
101.3
60.6
161.8
44.7
72.4
67.9
109.9
2019
102.3
61.7
164.0
30.9
50.7
74.7
122.5
103.3
62.9
166.2
20.7
34.5
78.0
129.6
2020
104.4
64.0
168.4
14.3
24.0
81.1
136.6
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6. Summary
In this final rule with comment
period, the burden estimate and analysis
of the impact of the policies result in a
total cost reduction estimated at
$48,534,332 at the lowest and
$63,359,464 at the highest for an EHR
reporting period on an annual basis for
2015 through 2017. For further
information on prior estimates of
program costs we direct readers to the
Stage 2 final rule (77 FR 54145).
The total cost to the Medicare and
Medicaid programs between 2017 and
2020 is estimated to be $3.7 billion in
transfers.
TABLE 40ESTIMATED EHR INCENTIVE PAYMENTS AND BENEFITS IMPACTS ON THE MEDICARE AND MEDICAID PROGRAMS
OF THE HITECH EHR INCENTIVE PROGRAM (FISCAL YEAR)
[in billions]
Medicare eligible
Fiscal year
Hospitals
2017 .........................................................................................................
26 Shekelle et al. 2013 Health Information
Technology: An Updated Systemic Review with a
Focus on Meaningful Use Functionalities.
27 Greiger et al. 2007, A Pilot Study to Document
the Return on Investment for Implementing an
Ambulatory Electronic Health Record at an
Academic Medical Center http://
www.journalacs.org/article/S10727515%2807%2900390-0/abstract-article-footnote-1.
28 DeLeon et al. 2010, The business end of health
information technology.
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$1.6
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Medicaid eligible
Hospitals
$0.3
$0.4
Professionals
$0.8
Total
$3.1
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62939
TABLE 40ESTIMATED EHR INCENTIVE PAYMENTS AND BENEFITS IMPACTS ON THE MEDICARE AND MEDICAID PROGRAMS
OF THE HITECH EHR INCENTIVE PROGRAM (FISCAL YEAR)Continued
[in billions]
Medicare eligible
Fiscal year
Hospitals
Medicaid eligible
Professionals
Hospitals
Professionals
Total
2018 .........................................................................................................
2019 .........................................................................................................
2020 .........................................................................................................
0.0
0.0
0.0
0.2
0.2
0.1
0.1
0.0
0.0
0.5
0.3
0.2
0.4
0.1
0.1
Total ..................................................................................................
1.6
0.2
0.5
1.8
3.7
TABLE 41ACCOUNTING STATEMENT FOR MODIFICATIONS: CLASSIFICATION OF ESTIMATED COST REDUCTIONS AND
BENEFITS CYS 2015 THROUGH 2017
[in millions]
Category
Benefits
Annualized Monetized Cost Reductions to Private Industry Associated with
Reporting Requirements ................................................................................
2015
Low
estimate
High
estimate
$52.8
$52.8
$68.9
$68.9
7%
3%
CYs 20152017.
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(2) Stage 3
Expected qualitative benefits include
improved quality of care, better health
outcomes, reduced errors and the like.
Private industry costs would include the
impact of EHR activities such as
temporary reduced staff productivity
related to learning how to use the EHR,
the need for additional staff to work
with HIT issues, and administrative
costs related to reporting. Transfers
related to the payment of EHR Incentive
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TABLE 42STAGE 3ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES CYS 2017 THROUGH
2020
[in millions]
Category
Benefits
Qualitative ..........................................................................................................
Estimates
(in millions)
Unit
discount
rate
Period covered.
Primary estimate
Annualized Monetized Costs to Private Industry Associated with Reporting
Requirements.
QualitativeOther private industry costs associated with the adoption of EHR
technology.
2017
$478.1
$478.4
7%
3%
CY 2017.
Year
dollar
Estimates
(in millions)
Unit
discount
rate
2017
$1,000.4
$954.8
7%
3%
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CYs 20172020.
412.64
Period covered
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(2)(iii)(D), as paragraphs (2)(i)(A),
(2)(i)(B), (2)(i)(C) introductory text and
(2)(i)(C)(1), (2)(i)(C)(2), (2)(i)(C)(3), and
(2)(i)(C)(4), respectively.
v. Adding new paragraphs (2)(i)
introductory text.
vi. Adding new paragraphs (2)(ii) and
(iii).
D. Amending the definition of EHR
reporting period for a payment
adjustment year by:
i. Redesignating paragraphs (1)(i)(A),
(1)(i)(B), (1)(ii), (1)(iii)(A), and (1)(iii)(B)
as paragraphs (1)(i)(A)(1), (1)(i)(A)(2),
(1)(i)(B), (1)(i)(C)(1) and (1)(i)(C)(2),
respectively.
ii. In newly redesignated paragraph
(1)(i)(A)(1), by removing the crossreference paragraphs (1)(i)(B), (ii), and
(iii) and adding in its place the crossreference paragraphs (1)(i)(A)(2),
(1)(i)(B), and (1)(i)(C).
iii. In newly redesignated paragraph
(1)(i)(A)(2), by removing the crossreference paragraphs (1)(iii) or (1)(iv)
and adding in its place the crossreference paragraph (1)(i)(C).
iv. Adding new paragraph (1)(i)
introductory text.
v. Adding new paragraph. (1)(ii)).
vi. Redesignating paragraphs (2)(i)(A),
(2)(i)(B), (2)(ii), (2)(iii)(A), and (2)(iii)(B)
as paragraphs (2)(i)(A)(1), (2)(i)(A)(2),
(2)(i)(B), (2)(i)(C)(1), and (2)(i)(C)(2),
respectively.
vii. In newly redesignated paragraph
(2)(i)(A)(1), by removing the crossreference paragraphs (2)(i)(B), (ii), and
(iii) and adding in its place the crossreference paragraphs (2)(i)(A)(2),
(2)(i)(B), and (2)(i)(C).
viii. In newly redesignated paragraph
(2)(i)(A)(2), by removing the crossreference paragraph (2)(iii) and
adding in its place the cross-reference
paragraph (2)(i)(C).
ix. Adding new paragraph (2)(i)
introductory text.
x. Adding new paragraphs (2)(ii) and
(iii).
xi. Redesignating paragraphs (3)(i) and
(3)(ii) as paragraphs (3)(i)(A) and
(3)(i)(B).
xii. In newly redesignated paragraph
(3)(i)(A), by removing the crossreference paragraph (3)(ii) and adding
in its place the cross-reference
paragraph (3)(i)(B).
xiii. Adding new paragraph (3)(i)
introductory text.
xiv. Adding new paragraphs (3)(ii)
and (iii).
e. Amend the definition of
Meaningful EHR user by:
i. In paragraph (1), by removing the
reference 495.8 and adding in its
place the reference 495.40.
ii. In paragraph (1), by removing the
reference under 495.6 and adding
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Definitions.
*
*
*
*
API stands for application
programming interface.
Certified electronic health record
technology (CEHRT) means the
following:
(1) For any Federal fiscal year or
calendar year before 2018, EHR
technology (which could include
multiple technologies) certified under
the ONC Health IT Certification Program
that meets one of the following:
(i) The 2014 Edition Base EHR
definition (as defined at 45 CFR
170.102) and has been certified to the
certification criteria that are necessary
to be a Meaningful EHR User (as defined
in this section), including the applicable
measure calculation certification
criterion at 45 CFR 170.314(g)(1) or (2)
for all certification criteria that support
a meaningful use objective with a
percentage-based measure.
(ii) Certification to
(A) The following certification
criteria:
(1) CPOE at
(i) 45 CFR 170.314(a)(1), (18), (19) or
(20); or
(ii) 45 CFR 170.315(a)(1), (2) or (3).
(2)(i) Record demographics at 45 CFR
170.314(a)(3); or
(ii) 45 CFR 170.315(a)(5).
(3)(i) Problem list at 45 CFR
170.314(a)(5); or
(ii) 45 CFR 170.315(a)(6).
(4)(i) Medication list at 45 CFR
170.314(a)(6); or
(ii) 45 CFR 170.315(a)(7).
(5)(i) Medication allergy list 45 CFR
170.314(a)(7); or
(ii) 45 CFR 170.315(a)(8).
(6)(i) Clinical decision support at 45
CFR 170.314(a)(8); or
(ii) 45 CFR 170.315(a)(9).
(7) Health information exchange at
transitions of care at one of the
following:
(i) 45 CFR 170.314(b)(1) and (2).
(ii) 45 CFR 170.314(b)(1), (b)(2), and
(h)(1).
(iii) 45 CFR 170.314(b)(1), (b)(2), and
(b)(8).
(iv) 45 CFR 170.314(b)(1), (b)(2),
(b)(8), and (h)(1).
(v) 45 CFR 170.314(b)(8) and (h)(1).
(vi) 45 CFR 170.314(b)(1), (b)(2), and
170.315(h)(2).
(vii) 45 CFR 170.314(b)(1), (b)(2),
(h)(1), and 170.315(h)(2).
(viii) 45 CFR 170.314(b)(1), (b)(2),
(b)(8), and 170.315(h)(2).
(ix) 45 CFR 170.314(b)(1), (b)(2),
(b)(8), (h)(1), and 170.315(h)(2).
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90-day period within CY 2016 and 2017
applies for the FY 2017 and 2018
payment adjustment years. For the FY
2017 payment adjustment year, the EHR
reporting period must end before and
the eligible hospital must successfully
register for and attest to meaningful use
no later than October 1, 2016.
(2) If in a prior year an eligible
hospital has successfully demonstrated
it is a meaningful EHR user, the EHR
reporting period is CY 2016 and applies
for the FY 2018 payment adjustment
year.
(C) In 2017 as follows:
(1) If an eligible hospital has not
successfully demonstrated it is a
meaningful EHR user in a prior year, the
EHR reporting period is any continuous
90-day period within CY 2017 and
applies for the FY 2018 and 2019
payment adjustment years. For the FY
2018 payment adjustment year, the EHR
reporting period must end before and
the eligible hospital must successfully
register for and attest to meaningful use
no later than October 1, 2017.
(2) If an eligible hospital is
demonstrating Stage 3 of meaningful use
under 495.24, the EHR reporting
period is any continuous 90-day period
within CY 2017 and applies for the FY
2019 payment adjustment year.
(3) If in a prior year an eligible
hospital has successfully demonstrated
it is a meaningful EHR user, the EHR
reporting period is CY 2017 and applies
for the FY 2019 payment adjustment
year.
(iii) The following are applicable
beginning in 2018:
(A) Except as provided in paragraph
(2)(iii)(B) of this definition, the EHR
reporting period is the calendar year
that is 2 years before the payment
adjustment year.
(B) If an eligible hospital is
demonstrating under the Medicaid EHR
Incentive Program that it is a
meaningful EHR user for the first time
in the calendar year that is 2 years
before the payment adjustment year, the
EHR reporting period for that payment
adjustment year is the same continuous
90-day period that is the EHR reporting
period for the Medicaid incentive
payment within the calendar year that is
2 years before that payment adjustment
year.
(3) * * *
(i) The following are applicable before
2015:
*
*
*
*
*
(ii) The following are applicable for
2015, 2016, and 2017:
(A) In 2015 as follows:
(1) The EHR reporting period is any
continuous 90-day period within the
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[Redesignated as 495.20]
[Redesignated as 495.40]
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paragraphs (e)(3)(ii)(A)(2) and (3) of this
section for an EHR reporting period in
2016.
(1) Alternate measure 1 in 2015.
Subject to paragraph (d) of this
section
(i) More than 30 percent of all unique
patients with at least one medication in
their medication list seen by the EP
during the EHR reporting period have at
least one medication order entered
using CPOE; or
(ii) More than 30 percent of
medication orders created by the EP
during the EHR reporting period are
recorded using computerized provider
order entry.
(2) Alternate exclusions in 2015. An
EP scheduled to be in Stage 1 in 2015
may exclude the measures specified in
paragraphs (e)(3)(ii)(A)(2) and
(e)(3)(ii)(A)(3) of this section in 2015.
(3) Alternate exclusions in 2016. An
EP scheduled to be in Stage 1 in 2016
may exclude the measure specified in
paragraph (e)(3)(ii)(A)(3) of this section
in 2016.
(iii) Eligible hospital and CAH
measures. (A) An eligible hospital or
CAH must meet the following 3
measures, subject to paragraph (d) of
this section:
(1) More than 60 percent of
medication orders created by authorized
providers of the eligible hospitals or
CAHs inpatient or emergency
department (POS 21 or 23) during the
EHR reporting period are recorded using
computerized provider order entry.
(2) More than 30 percent of laboratory
orders created by authorized providers
of the eligible hospitals or CAHs
inpatient or emergency department
(POS 21 or 23) during the EHR reporting
period are recorded using computerized
provider order entry.
(3) More than 30 percent of radiology
orders created by authorized providers
of the eligible hospitals or CAHs
inpatient or emergency department
(POS 21 or 23) during the EHR reporting
period are recorded using computerized
provider order entry.
(B) Alternate exclusions and
specifications. (1) An eligible hospital or
CAH previously scheduled to be in
Stage 1 in 2015 may meet an alternate
measure specified in paragraph
(e)(3)(iii)(B)(2) of this section in place of
the measure outlined under paragraph
(e)(3)(iii)(A)(1) of this section, and may
exclude the measures outlined under
paragraphs (e)(3)(iii)(A)(2) and
(e)(3)(iii)(A)(3) of this section for an
EHR reporting period in 2015. An
eligible hospital or CAH previously
scheduled to be in Stage 1 in 2016 may
exclude the measures outlined under
paragraphs (e)(3)(iii)(A)(2) and (3) of
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(e)(8)(iii)(A)(2) of this section for an
EHR reporting period in 2015.
(9) Secure messaging(i) EP
objective. Use secure electronic
messaging to communicate with
patients on relevant health information.
(ii) EP measure(A) Measure. For an
EHR reporting period
(1) In 2015, the capability for patients
to send and receive a secure electronic
message with the EP was fully enabled
during the EHR reporting period;
(2) In 2016, for at least 1 patient seen
by the EP during the EHR reporting
period, a secure message was sent using
the electronic messaging function of
CEHRT to the patient (or the patientauthorized representative), or in
response to a secure message sent by the
patient (or the patient-authorized
representative) during the EHR
reporting period; and
(3) In 2017, for more than 5 percent
of unique patients seen by the EP during
the EHR reporting period, a secure
message was sent using the electronic
messaging function of CEHRT to the
patient (or the patient-authorized
representative), or in response to a
secure message sent by the patient (or
the patient-authorized representative)
during the EHR reporting period.
(B) Exclusion in accordance with
paragraph (b)(2) of this section. An EP
may exclude from the measure if he or
she
(1) Has no office visits during the EHR
reporting period; or
(2) Conducts 50 percent or more of his
or her patient encounters in a county
that does not have 50 percent or more
of its housing units with 4Mbps
broadband availability according to the
latest information available from the
Federal Communications Commission
on the first day of the EPs EHR
reporting period.
(C) Alternate specification. An EP
previously scheduled to be in Stage 1 in
2015 may exclude the measure specified
in paragraph (e)(9)(ii)(A) of this section
for an EHR reporting period in 2015.
(10) Public Health Reporting(i) EP
Public Health Reporting(A) Objective.
The EP is in active engagement with a
public health agency to submit
electronic public health data from
CEHRT, except where prohibited, and in
accordance with applicable law and
practice.
(B) Measures. In order to meet the
objective under paragraph (e)(10)(i)(A)
of this section, an EP must choose from
measures 1 through 3 (as specified in
paragraphs (e)(10)(i)(B)(1) through (3) of
this section) and must successfully
attest to any combination of two
measures. The EP may attest to measure
3 (as specified in paragraph
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(i) Must ensure that the objective in
paragraph (d) of this section includes an
option to meet 2 out of the 3 associated
measures.
(ii) Meets the threshold for 2 out of
the 3 measures for that objective.
(iii) Attests to all 3 of the measures for
that objective.
(3) Exclusion for non-applicable
objectives and measures. (i) An eligible
hospital or CAH may exclude a
particular objective that includes an
option for exclusion contained in
paragraph (d) of this section, if the
eligible hospital or CAH meets all of the
following requirements:
(A) Meets the criteria in the
applicable objective that would permit
the exclusion.
(B) Attests to the exclusion.
(ii) An eligible hospital or CAH may
exclude a measure within an objective
which allows for a provider to meet the
threshold for 2 of the 3 measures, as
outlined in paragraph (b)(2) of this
section, in the following manner:
(A)(1) Meets the criteria in the
applicable measure or measures that
would permit the exclusion; and
(2) Attests to the exclusion or
exclusions.
(B)(1) Meets the threshold; and
(2) Attests to any remaining measure
or measures.
(4) Exception for Medicaid eligible
hospitals or CAHs that adopt,
implement or upgrade in their first
payment year. For Medicaid eligible
hospitals or CAHs who adopt,
implement or upgrade CEHRT in their
first payment year, the meaningful use
objectives and associated measures of
the Stage 3 criteria specified in
paragraph (d) of this section apply
beginning with the second payment
year, and do not apply to the first
payment year.
(c) Objectives and associated
measures in paragraph (d) of this
section that rely on measures that count
unique patients or actions. (1) If a
measure (or associated objective) in
paragraph (d) of this section references
paragraph (c) of this section, then the
measure may be calculated by reviewing
only the actions for patients whose
records are maintained using CEHRT. A
patients record is maintained using
CEHRT if sufficient data was entered in
the CEHRT to allow the record to be
saved, and not rejected due to
incomplete data.
(2) If the objective and associated
measure does not reference this
paragraph (c) of this section, then the
measure must be calculated by
reviewing all patient records, not just
those maintained using CEHRT.
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(iv) For an EHR reporting period in
2017 only, an EP may meet a threshold
of 5 percent instead of 10 percent for the
measure at paragraph (d)(6)(i)(B)(1) of
this section.
(2) During the EHR reporting period
(i) For an EHR reporting period in
2017 only, for more than 5 percent of all
unique patients seen by the EP during
the EHR reporting period, a secure
message was sent using the electronic
messaging function of CEHRT to the
patient (or their authorized
representatives), or in response to a
secure message sent by the patient; or
(ii) For an EHR reporting period other
than 2017, for more than 25 percent of
all unique patients seen by the EP
during the EHR reporting period, a
secure message was sent using the
electronic messaging function of CEHRT
to the patient (or their authorized
representatives), or in response to a
secure message sent by the patient.
(3) Patient generated health data or
data from a nonclinical setting is
incorporated into the CEHRT for more
than 5 percent of all unique patients
seen by the EP during the EHR reporting
period.
(C) Exclusions in accordance with
paragraph (a)(3) of this section. (1) Any
EP who has no office visits during the
reporting period may exclude from the
measures specified in paragraphs
(d)(6)(i)(B)(1), (2), and (3) of this section.
(2) Any EP that conducts 50 percent
or more of his or her patient encounters
in a county that does not have 50
percent or more of its housing units
with 4Mbps broadband availability
according to the latest information
available from the FCC on the first day
of the EHR reporting period may
exclude from the measures specified in
paragraphs (d)(6)(i)(B)(1), (2), and (3) of
this section.
(ii) Eligible hospital and CAH
coordination of care through patient
engagement(A) Objective. Use CEHRT
to engage with patients or their
authorized representatives about the
patients care.
(B) Measures. In accordance with
paragraph (b)(2) of this section, an
eligible hospital or CAH must satisfy 2
of the 3 following measures in
paragraph (d)(6)(ii)(B)(1), (2), and (3) of
this section, except those measures for
which an eligible hospital or CAH
qualifies for an exclusion under
paragraph (b)(3) of this section.
(1) During the EHR reporting period,
more than 10 percent of all unique
patients (or their authorized
representatives) discharged from the
eligible hospital or CAH inpatient or
emergency department (POS 21 or 23)
actively engage with the electronic
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(i) Does not diagnose or directly treat
any disease or condition associated with
a public health registry in the EPs
jurisdiction during the EHR reporting
period.
(ii) Operates in a jurisdiction for
which no public health agency is
capable of accepting electronic registry
transactions in the specific standards
required to meet the CEHRT definition
at the start of the EHR reporting period.
(iii) Operates in a jurisdiction where
no public health registry for which the
EP, eligible hospital, or CAH is eligible
has declared readiness to receive
electronic registry transactions as of 6
months prior to the start of the EHR
reporting period.
(5) Any EP meeting at least one of the
following criteria may be excluded from
the clinical data registry reporting
measure specified in paragraph
(d)(8)(i)(B)(5) of this section if the EP:
(i) Does not diagnose or directly treat
any disease or condition associated with
a clinical data registry in their
jurisdiction during the EHR reporting
period.
(ii) Operates in a jurisdiction for
which no clinical data registry is
capable of accepting electronic registry
transactions in the specific standards
required to meet the CEHRT definition
at the start of the EHR reporting period.
(iii) Operates in a jurisdiction where
no clinical data registry for which the
EP, eligible hospital, or CAH is eligible
has declared readiness to receive
electronic registry transactions as of 6
months prior to the start of the EHR
reporting period.
(ii) Eligible hospital and CAH Public
Health and Clinical Data Registry:
Reporting objective(A) Objective. The
eligible hospital or CAH is in active
engagement with a public health agency
(PHA) or clinical data registry (CDR) to
submit electronic public health data in
a meaningful way using CEHRT, except
where prohibited, and in accordance
with applicable law and practice.
(B) Measures. In order to meet the
objective under paragraph (d)(8)(ii)(A)
of this section, an eligible hospital or
CAH must choose from measures 1
through 6 (as described in paragraphs
(d)(8)(ii)(B)(1) through (6) of this
section) and must successfully attest to
any combination of four measures.
These measures may be met by any
combination, including meeting the
measure specified in paragraph
(d)(8)(ii)(B)(4) or (5) of this section
multiple times, in accordance with
applicable law and practice:
(1) Immunization registry reporting.
The eligible hospital or CAH is in active
engagement with a public health agency
to submit immunization data and
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(a) * * *
(2) * * *
(i) * * *
(B) For calendar years before 2015,
satisfied the required objectives and
associated measures under 495.20 for
the EPs stage of meaningful use.
*
*
*
*
*
(E) For CYs 2015 through 2017,
satisfied the required objectives and
associated measures under 495.22(e)
for meaningful use.
(F) For CY 2017 only, an EP may
satisfy either of the following objectives
and measures for meaningful use:
(1) Objectives and measures specified
in 495.22 (e); or
(2) Objectives and measures specified
in 495.24 (d).
*
*
*
*
*
(b) * * *
(2) * * *
(i) * * *
(B) For fiscal years before 2015,
satisfied the required objectives and
associated measures under 495.20 for
the eligible hospital or CAHs stage of
meaningful use.
*
*
*
*
*
(E) For CYs 2015 through 2017,
satisfied the required objectives and
associated measures under 495.22(e)
for meaningful use.
(F) For CY 2017 only, an eligible
hospital or CAH may satisfy either of
the following objectives and measures
for meaningful use:
(1) Objectives and measures specified
at 495.22(e); or
(2) Objectives and measures specified
at 495.24(d).
(G) For CY 2018 and subsequent
years, satisfied the required objectives
and associated measures under
495.24(d) for meaningful use.
*
*
*
*
*
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495.310
[Amended]
*
*
*
*
(c) Subject to 495.332 and 495.352,
the State is required to submit to CMS
annual reports, in the manner
prescribed by CMS, on the following:
*
*
*
*
*
(d) * * *
(2) * * *
(iii) Subject to 495.332, the State
may propose a revised definition for
Stage 3 of meaningful use of CEHRT,
subject to CMS prior approval, but only
with respect to the public health and
clinical data registry reporting objective
described in 495.24(d)(8).
*
*
*
*
*
(f) Each State must submit to CMS the
annual report described in paragraph (c)
of this section within 60 days of the end
of the second quarter of the Federal
fiscal year.
(g) The State must, on a quarterly
basis and in the manner prescribed by
CMS, submit a report(s) on the
following:
(1) The State and payment year to
which the quarterly report pertains.
(2) Subject to paragraph (h)(2) of this
section, provider-level attestation data
for each EP and eligible hospital that
attests to demonstrating meaningful use
for each payment year beginning with
2013.
(h)(1) Subject to paragraph (h)(2) of
this section, the quarterly report
described in paragraph (g) of this
section must include the following for
each EP and eligible hospital:
(i) The payment year number.
(ii) The providers National Provider
Identifier or CCN, as appropriate.
(iii) Attestation submission date.
(iv) The state qualification.
(v) The state qualification date, which
is the beginning date of the providers
EHR reporting period for which it
demonstrated meaningful use.
(vi) The State disqualification, if
applicable.
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(vii) The State disqualification date,
which is the beginning date of the
providers EHR reporting period to
which the provider attested but for
which it did not demonstrate
meaningful use, if applicable.
(2) The quarterly report described in
paragraph (g) of this section is not
required to include information on EPs
who are eligible for the Medicaid EHR
incentive program on the basis of being
a nurse practitioner, certified nursemidwife or physician assistant.
14. Section 495.352 is revised to read
as follows:
495.352
Reporting requirements.
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